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68/11/2664 69 27 26946B3433 FIFTH FLOOR PAGE 63 <br />' �.1 �' n Joaquin County O r lur r <br /> �I t''r7 � �� 11 v <br /> mental Health Department 1�� %Ar,—u <br /> 304 East weber Avenue,3rd Floor,Stockton,CA 95202 AUG 0 9 Z004MITIGATION <br /> 1 ` (2rJ9)468-34A9Fax (209)A68-3433 Web-www.sjgay.ar9 , I Uf�PJIENT NEALTHI.INIT IV <br /> Po - MIT/SEIRVICLESU <br /> tNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED WD 4p, PA <br /> Applwation is hereby made to San Joaquin County for a permit 10 construct and/or Install the work descnbed This application is made in compiianee with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin County Envlronmental Health Department <br /> � <br /> Assessors <br /> ��[r�2 y <br /> _ <br />' WELL Location � Gross Street <7SO i'aisel#�+F'l <br /> Location �c <br /> pwaerEi Address G� Lti-ii�O�p C dys ` '7 Zip��ions# C? -J-7r { 7 C:1{ <br /> �-y� �,- ,,��(� �r j,, +Zrv1Ctlti0 C <br /> C-57 Canlractor(-LL c�N� ' Address_ <br /> Consultant f Sub Cnir <br /> &C_P_ Address- C lr �fJ Lo rte:i t Crty�6Y'.t�vl�L is Phone# %4-, <br /> 1 GIS Coordinates X 'y ,Township. Range Section <br /> WORK TO BE PERFORMED <br /> NEW WELL r BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,GTHEIr) j ESTRUCTION (choose typ f f r <br /> n SOIL BORINr=;m VER-BORE DIAMETE <br /> p PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONSAp <br /> ICOMMENTS ;C± MI_IITCf4 _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />' MONITORING XHOLLOW STEM DIA OF BOREHOLE 3S13 MULTiI�PLE CASINGS a MULTI-LEVEL 1MELL CASING DLOL C2 <br /> n EXTRACTION BAIR HAMMER/DRIVEN CASING THICKNESSO rOii`S[Lte3 TYPE OF CAsiNG D STEEL -�ffIaVC U OTHER <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED D AUGE=RS ;R;HOSZ <br />' IR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED. kYes II No (NOTE: MAXIMUM FREE-FALL DEPTH TS 38') <br /> OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER. _ p OTHER APPROX BORING DEPTIi__)7 MOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ICONDUCTOR CASING PROPOSED (rl YES,list specifications in comment section) <br /> COMMENTS, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> A8 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS_ <br /> I hereby certify that I have preps ed this applica n and that the work will be done in accordance with San Joaquin <br /> County Ordlnan , Rules a d egtlla# s, a all applicable California State Laws. <br /> Z <br /> Signed x TIUe/Campany - <br /> rx&'Al <br /> Print Name 1 �YJ� f��u+�lT ! `' —Dale- - Dale (E � r <br /> DEPARTMENT USE O Y <br /> CW <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� ` ALSO <br /> �� .' <br /> WORK PLAN DATED: O)9 _ <br /> A,pp6sat+on Accepted By <br /> Date Issued cowltor Area!+ <br /> Grout Inspection By pate Flnal Inspection By Date <br /> Destnrctlon Ir[spectrnn By Date <br /> COMMENTS I CONDMONS <br /> ACCOl1NTiAlG ONLY AID# FAQ <br /> CODES FEE INFO AMOUNT REINUTTED CHECK 9 RECD BY DATE PERMIT I SERVICE REQUEST I INVOICE <br /> —ajtD Z1�► ,r SR# ,! <br /> C-57 WC -WAIVER C-57 Letter of Authorization to s+gn perm+ Er+rrraQchmt dnc <br /> E1�z+a-ax-0v i <br /> 9130/2003 <br />