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FROM :Water Well tvKOnogy Inc FAX NO. :19164800839 Mar. 2B 2005 02:t72PM P1 <br /> I <br /> H Eq u yy u Joaquin County <br /> AR XIv1� mental Health Department SITE <br /> 304 Eavt TO 'T Avenuo,3rd Floor,Stockton,CA 95202 MITIGATION <br /> ENVIE W9"4i1(-'A>EarN209)468-3433 Web:www.kjgov.org/ehd UNIT IV <br /> PERMIT/SER\Wjj permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permilto construct and/or Install the wont described. Thla application Is made In compliance with San <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards of San Joaquin County EnNronm°ntal Heath Depart. <br /> tmen �Z <br /> Assessars <br /> WELL Leeetlen ISO'/ S. 1� M �.� cruse streae city.iE,+eh&�np Parceka 1 003 <br /> trCr"elz PROPeRTy /� <br /> owner (..On'±o:6a­00 #A'J.Addres&vAa 7 PA-At,k AA Hit E ltyAL4f YriC zip 1017,1 Pan"Cala1) 1?O(7_-.S��I�O <br /> C•67 ConlractorZSe44.n7SOArC,Tft Address a-20 A)-'44 � City Op � /d'"Z�IP�vs��LiEg L33'-none/U�) 1x8 1Ya4 <br /> conaulmnt/Sub Cntr c _ ,r t_Addroae, S'la1J_&rl!s a+,.�"�!".).Cnf'. JF.�aM' >C,idf„__...__�...._PhoneN "-S9Wa <br /> 018 Coordinates:X_Y ,Township , 5 RaneeSection 02 <br /> RK <br /> Wt;LL/BORI <br /> RPO ED: <br /> EW NO (CPT,GEOPROBE,HYOROPIJNCH,HANO-AUGER,OTHER-) 0 DESTRUCTION (choosa type below) <br /> 0 SOILBOR /t 0 OVER-BORE. DIAMETER, <br /> �WELLM1b0l 1 /• aPRESSURF GROUT <br /> II"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYRE OF LNJL6 IN 6LLATIO TY CONSTRUCTION SPECIFICATIONS <br /> ONITORING OLLOW STEM DIA.OF BOREHOLE A) H MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION g AIR HAMMERMRIVEN CASING THICKNESS_TYPE OF CASING: Q STEEL PVC BOTHER:- <br /> 1] <br /> OTHER:0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL. TREMIE TYPE TO BE USED! 0 AUGERS 0 HOSE <br /> O AIR SPARGEI OZONE 0PUSH POINT(GP or CPT)GROUT SEAL PUMPED: BY" 0No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> O OTHER; Q OTHER APPROX.BORING DEPTH BOLTED TRAFFiC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (e YES,list spedflcatione 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 In accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> Stand x TitWGomPany _ <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> AppllCatlDn Accepted By Date Issued me <br /> Grout Inspection By Onle Final lnspoalon By Date <br /> Oeslrumon oupecilon By r Date 11 <br /> / L7 <br /> COMMENTSICONDI,10N8• I, " I nJ1A <br /> ACCOUNTING ONLY: A N rI t)l Z PACO _ <br /> PEPS FEE INFO AMOUNT REMITTED CH <br /> OODECK8 ReI BY DATE PERMIT I SERVICE REQUEST <br /> °1101 �9 4A Snit <br /> G-57_ WC--WAIVER_ C-57 Letter of Authorization to Sign parvnit_Encroachment doc— <br /> EHD 29.02401 <br /> 6122/04 <br />