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Uel LlI LCJUJ 14 Ul 4CJ74 b034­5.7� f•Lr Irl rLUUN PAGE 02 <br /> � San Joaquin County COPY <br /> F- mental Health Department SITE <br /> • PJ - --,cTer Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax (209)468.3433 Web www sjgov orglehd UNIT IV <br /> d i Q 1siAjl - 'nflgWell Permit Application <br /> U,aV1r owl , �` pI7 I • GoS <br /> rq - FUI ?�13R E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r �T. - - -- <br /> Appllcabon Is hereby mado to an Joequm C riy far a permit to construct andfor lr�mall the work described Thm application Is made In compliance with San <br /> Joaquin County Development Title,Chapter 9 1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> coKwtr3rK L IK4 1!,%"l Asseseors <br /> WELL Loeatlon&I�-k/ �c-t 47L+ tY1t t/ _Cross Street �-Li t /Cjl�-_ Zip 4qs2G`1 Per,,,#_ <br /> PRO"" �GK�� <br /> Owner _= � a{ -1 fol-k+0.,-Address '1z-9y �{ Von.ted 5 o Clty . _z;p 9 s;W'/Phonc# <br /> 1C-S7Contraclor C,,eg �rdl,w _ Addross :�`i7rCere-d,5% yc Crty5, ° Zip f`�hlc#GS6"rv'�Phone# 56 <br /> ctpckJ <br /> Cor:sultant/Sub Cntr-SaOgKt�f a of d�{l Address��l 7 K�1��`e +Td P�", Clt5- :D �k Llc# Phone# "10 <br /> GIS Coordinates X Y Township_ __- Range 5evtwi <br /> WORK TO EE IP R <br /> IZ1JEW WI»1.L 1 T GEOPROBE HYDROPUNCH HAND-AUGI"-R OTHER-) p DESTRUCTION (choosc type below) <br /> SOIL BORING# G P!- a OVER-80RE DIAMETER - <br /> ! PRESSURE GROUT' <br /> 'Other GROUT SPECIFICATIONS <br /> COMMENTS _ <br /> TYP _Q WELL INSTALLATfOt4-TYPE PPNSTRUCTION SPECIFICATIONS <br /> I]MONITORING 0 HOLLOW 5TEM PIA OF BOREHOLE Z s"0 MULTIPL5 CASINGS 0 MULTI-LEVEL WELL CAS€NG DIA <br /> U EXTRACTION o AIR HAMMER/DRIVEN CASING THICKN535TYPE OF CASING 1]STEEL p PVC 8 OTHER <br /> D VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 1t O F7 TREMIE TYPE TO BE USED n AUGERS p HOSE <br /> p AIR SPARGEJ OZONE PUSH POINT(GP or6pGROUT 51=AL PUMPED gYes Q No (NOTE- MAXIMUM FREE-FALL DEPTH IS SO') <br /> qwSOIL BORING U HANG AUGER GROUT SPECIFICATIONS A,,j :*-. C e�e n f <br /> D OTHER 0 OTHER APPROX BORING DEPTH_ 110 ft - - 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED VQ _(if YES Ilst specifications In comment section) <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done to accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws <br /> Signed x_..-2----- -—- -- _ _ TMetGompany €a�C R7,^ X-­4 <br /> Print Name Dl Ci v. Love <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS. <br /> WORK PLAN DATED. <br /> Appteaborl Accepted By Date Issued 3~—z E ­05 5 Area <br /> Grout Inspeotton By 1z Date_ _ _ Flnal Inspection toy _ _ _ _ _Date <br /> DestrucWn Inspection By Date <br /> COMMENTS i CONDITIONS <br /> ACCOUNTING ONLY Alb# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK$ REC'D BY DATE PERMt7!SERVICE REQUEST# INVOICE <br /> WC. WAIVEP --- . C-57 Letter of Authortzation to sign pertnit,2,Encroachment dQ <br /> END 29-02-001 05"-01 W f <br /> 6127.!04 <br /> I <br />