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SAN JOA QUIN COUNTY NTY 600 East Main Street Stockton, CTH A 5202- y`'IL') h 2 33 ZDG8Te%phone:(209)468-3449 Fax: ARTME• (209)468-3433 Web: 30291 SITE ENVi ONlb',LNI HEALTH 35 W ov.or /ehd MITIGATION PER4^I7/SERV;CFS WELL PERMIT APPLICATION NON-REFUND _ UNIT ►V APPl)cation is hereby made to NON-REFUNDABLE — Joaquin Count San Joaquin CountyE PERMIT EXPIRES 1 County Development Title,chat -1115 for a YEAR FROM DATE ISSUED chapter 9- Permit to construct and/or in Well Location 5950 7175.3 and the Standards ofstall the Work described. ___ Woodbridge Rd. San Joaquin Property -- Cross street Kennefick Rd. County Environ This application is Owner RINE, Inc, mental Health Deoartment.ade in compliance with San City Acampo C•57 Contractor Vannucci Technologies Address _P.O, go-- c_Zip 95258 Assessor's Parcel# 017017-0 Consultant/Sub Cntr_Kenned Address 26251 "°tr.Acampo Madison St. �– Zip 95258 _ City Esparto Phone# 209-3= GIS Coordinates:X_6346983 Address-622 Folsom St. Lic# 814760 .37' _ City San Francisco Phone_530-219-2641 �:ORK TO -------- ' Y - 2243568.53' — Lic#_BE PERFORMED: —:Tnwnshin -_-Phone 415-243- ® NEW VIELL/BORING T4N —� 2150 (CP T,GEOPROBE,HYDROPUNCH,HAND- Range R7E BI SOIL BORING# � Section 31 ,WELL# AUGER,OTHER•) � ❑*OTHER ❑DESTRUCTION(CHOOSE TYPE BELOW) ❑OVER-BORE DIAMETER COMMENTS:_Geoprobe borings to 10 ft. bgs. for soilsamples. 0 PRESSURE GROUT GROUT SPECIFICATIONS TYPE OF WELL -I_NSTALLAT-11 MONITORING ;CONSTRUCTIONp!=CSTEMS❑HOLLOW A. —_ OF BOREHOLE _ 2-Inch 13 MULTIPLE CASINGS ❑EXTRACTION 11 AIR HAMMER/DRiVEN ❑MULTI-LEVEL CASING THICKNESS WeWELL CASING DIA:_ ❑VAPOR ❑MUD ROTARY ---- TYPE OF CASING:❑STEEL —� DEPTH OF GROUT SEAL 10-feet _7REMIE TYPE TO BE USED❑AUGERS❑H❑PVC ❑ OTHER El AIR SPARGFiOZONE PUSH POINT GP SE O� GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') KI SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Neat cement ❑OTHER ❑OTHER: APPROX BORING DEPTH 10-feet CONDUCrOR CASING PROPOSE^ ❑BOLTED TRAFFIC BOX OR COMMENTS: (if YES,list spetlfiwFIC lncomOR OS)OVEPIPE NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have prepared this applic un and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulatio and//aY applicabl Ca��lijjfornia Laws/- Signed&/4� "i ZA 414 Title/Company Pd Print Name Date 9 2 2 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: /4, WORK PLAN DATED: CU(QWLZL� _ P13 n - R 2cz'J APPLICATION ACCEPTED BY DATE ISSUEDjJ GROUT INSPECTION BY FINAL INSPECTION BY AREA_ DESTRUCTION INSPECTION BY DATE DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMI CHECK# RECV'D BY DAT _ PERMIT/SERVICE# INVOICE � QbI (- ej n 14&-- 9' Z SR#vOSM7 WC -WAIVER �C57 LETTER OF AUTHORIZATION TO SIGN PERMIT C-57 ENCROACHMENT DOC EHD 29-01 1115107(WEB) WELL PERMIT APP