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San Joaquin County <br /> Envitso mental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This 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 /> WELL Location, }� �[<<�to:vU 0- ��- Cross Street Dai.= � Cit ':4ck4y,_ Zi Assessors <br /> Y p ��J��- Parcel# <br /> PROPERTY r �/ <br /> Owner C-j0u�� all W c�tG� Address ( 0�� �-�ru�r YpC4titt��. City v1 Zip sZ-D LPhone# M'j1)i460Zg`_ <br /> C-57 Contractor cw'_ ( �trollit.r� Address X032 �NhE! etc+[ CityCa�a-1A Zipq(5 7 _&ic#���0hone# gl O 'G3 Y"!/(�ej <br /> Consultant/Sub Cntr Ahay ek `1?66 Vi(bjV&_WAddress j3_1 S" City Lic# 6 07 Z 7 Phone# _7Pj)t(,]"1W�a <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# I 0 OVER-BORE. DIAMETER <br /> 'WELL# 7� FILE COPY OGPRESSURE <br /> ROUT SPEC F CO <br /> 0*Other AT ONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. OF BOREHOLE qy MULTIPLE CASINGS h <br /> --1� D 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS D TYPE OF CASING: 0 STEEL PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL IyG�F Tse TREMIE TYPE TO BE USED: WUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: tjLYes 0 Not(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pef-N�4�1 <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 1;04 '-/j ;ZBOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: A)L�1 �rv1 -�2 OVl'� Sit,C7.1 bmAA" ? x j <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. iA n �-• I,I <br /> Signed x 7rdt�*11 - L'. J L- Title/Company 6fdo St /Adyayt4 l�� Gtyilirm (,t Qt ,W I'L'K. <br /> Print Name C_yr-c vi'E L Date t,) 2-c6' PC-', <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: o Z C-":6 '4 A d, , Sf Ell r r n Q V <br /> WORK PLAN DATED: ZC7'Os— <br /> Application Accepted By Date Issued_ 1 /� /O� Area <br /> L/ <br /> Grout Inspection By Date Final Inspection By 1,1:>,n-, ,_,�,,,�,, Date 2-e" <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: GJO W-C I <br /> ACCOUNTING ONLY AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 31-01 <br /> g `o0 2 30 2 I L� 106 S R# <br /> -o <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit✓ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />