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VIIEL . PERMil" APPL1CATIOfV E®1�M CSQIFYU <br /> �1 - © ,� TL <br /> Ti0[V <br /> SAN JOAQUIN COUNTY <br /> MENTAL HEALTH DEPARTMENT (E DV <br /> C� 1 <br /> ENVIRONMENTAL <br /> Weber;Third Floor, Stockton_, CA., 95202 AN <br /> 304 E. , <br /> a � aa3 <br /> (209} 4fi8-3449 0 �" W <br /> �NVERO��I�I>=�i f��xLT'ri <br /> p <br /> NON-REFUNDABLE PERMIT EXPIRES YEAR FROM DATE ISSUED URNIT/ ( �,�I(' S <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This appli a on s ma in ianCe with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standard`s of San Joaquin County Environmental Health <br /> Departmen„-tA <br /> ssessors <br /> � �Css Streetrf/6^_, City SC/rZip9fo3 Parce# 12,7 <br /> WELL Location IOi76 <br /> PROPERTY Owner Address 3 �•l.�•e'�hcr/ CEtyt MP3 Phone# .?.rte <br /> C-57 Contractor J Address Z3�rG� cs��n_City S7��CJ�++ Tip` .W-Uc#slu Phone#20yJE7/L <br /> Consultant 1 Sub Contractor 's45a 9 dress !3 � a� 'tCity�c#X13 6T7Phone#"0 45Cer = <br /> GIS Coordinates X tti/ /'� � Y—,- T7 08' Township lv Range 6 E coon <br /> WORK TO BE PERFORMED - �f}ESTRUCTION(ch type below} <br /> NEW WELL 1 BORING(CPT.GEOPROBE,HYDROPUNCH,NAND-AUGER,OTHER') r / ER-BORE <br /> a SOIL BORING# PR-W GROUT <br /> a WELL# �r <br /> *Other Grout Specifications Alfie �''� 1' <br /> IAMZV <br /> COMMEN S C!i Gam« � �0b �� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIOMS <br /> p MONITORING iJ HOLLOW STEM DIA_OF BOREHOLE MULTIPLE CASINGS?I]YES [)NO W ELL CASING DIA. <br /> RACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING Q STEEL 1]PVC 1]OTHER <br /> OR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED AUGERS HOSE <br /> p AIR SPARGE 13 PUSH POINT GROUT SEAL PUMPED 1]Yes Q]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 11 SOIL BORING (I HAND AUGER GROUT SPECIFICATIONS <br /> p <br /> OTHER,___:._[l OTHER. APPROX.BORING DEP 7i i 3 p BOLTED TRAFFIC BOX or 1)STOVE PIPE <br /> CONDUCTOR CASING PROPO ED? (if YES.list specifications here) <br /> -COMMENTS <br /> l <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I, ,' <br /> I hereby certify that I have prepared this application and that the work will be done In gccbrdance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x /`` Title/Company U•p•6 r <br /> Print Na e!e , e Date /A <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 9_& <br /> WORK PLANDATED: /0-/5 0 7.- tr'ti <br /> Y <br /> Applicatlon Accepted By -Date lss�!! �,ed -- D I—DZ~s O3 - 4^ Areae <br /> -- '- -- - Date ---- - Futal Inspection try +• Data <br /> Grout Inspection By <br /> Destniction InsWon 8y fate <br /> pe <br /> � T <br /> MENTS 1 CONDITIONS <br /> ACCOUNTING_ONLY Alm car`++ - t <br /> PE CODES FEE INFO AMOUNT REMI77EIQ CHECK# ~� RECD BY OKTE -` PERMrr I SERVICE REQUEST# WVOICE <br /> Shy 'VJA 5�3 y �t l•43s 00. 2-.Z-S� <br /> C-57 WC ✓ -WAIVER._. C-57 Letter of Authorization to sign perrrtrt Encroachment doc 1/251 <br />