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C' <br /> ,11� RECan Joaquin County L <br /> z :� )4y=mental Health Department SITE <br /> Q� <br /> AUG 30Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ` •�` ► '' (209)4 49 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ENVIRONMENT HEA <br /> RMIT/SERVICES"fell 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 /> --�� ^^�� �^ •t� �� Assessors <br /> WELL Location ID ct-o� r(t R --tE Wross Street LA LV,City�cr� Zip I S dtD Parcel#Z <br /> PROPERTY <br /> OwnerTttPcf•3 Address 1300 tobtj9TftA1hL City$tj CAp1.a5 Zip'&-10 Phone#0)596-895'0 <br /> C-57 Contractor�RG[//(� �Q L,-,j n Address 4b City Zr��Z`ip�� Lic#��Phone# 113 S706 <br /> Consultant/Sub Cntr i�*M%9-10, jtRaVC 1Address�� /�tLIS -A A City e V%\ Lic#Phone ill\ 2—g70D <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW LL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> OIL BORING# - Q OVER-BORE. DIAMETER <br /> WELL# Q PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: eY <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �' <br /> . MONITORING HOLLOW STEM DIA.OF BOREHOLE_ <br /> Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:�V�l <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL VPVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 112 TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> �S4 WAIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes 4No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> gy�1,80SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: (1 OTHER APPROX.BORING DEPTH 3�� BOLTED TRAFFIC BOX or L I Q STOVE PIPE <br /> y� 0 o CONDUCTOR CASING PROPOSED (ii-f••YES,list specifications in comment section) <br /> COMMENTS-,� ftty+�� tom-3$ M7� O•i)to"Sl� An-►,9Z�j Z �Yln vtl�te�l Sa.a� <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 epare this application and that the work will be done in accordance with San Joaquin <br /> Count Inan s, Rule a ulations, and all applicable California State Laws. rr �, <br /> Signed Title/Company '- -� •' 7tt�,f 1AMW � <br /> Print Name V.�11t1J 0.31,1 E L. — Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I Q 2- Z Fro n fa 4 p- Ro a J Hl'Qbtaaw 2q <br /> WORK PLAN DATED: Maw 1b -:2 D D <br /> Application Accepted By Vi r- ria L P L ifa r to P v Date Issued 8 8 - b 5- Area 1-459 <br /> Grout Inspection By%1C±Aria 1Y10- /0r+4A!9 Date 8-/S-b S Final Inspection By V1 CI-or:d YNL'ed -brA Date 8 -/7-OE <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: :r03+4jj.Qf:-f0n of bAw-jo and AS-1 ,i 1W <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUES of E <br /> 350 �GS.00 3G8. Da SR# 004 3 XG <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 />