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San Joaquin County <br /> En .mental Health DepartmeL ,„ 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 BURG III p� 3�.$4 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work des5r ,�hta, pplication is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environ fV�,'{tCy�U PI#ryIl��a <br /> WELL Location ROD 9101k 6.Wil Initw L y �% Ta«i#`� <br /> Cross Street �aS� Cit <br /> PROPEjj��11(( �� C "�� /� <br /> Owner[�tfy0�>/LC'�/'d A� K^--7UWttAddress .s Nfr1Lk /nRGf.o city Vyl, , n Zip_ 70 Phone# 37—y�.34g <br /> C-57 Contracto �'11 kjJ151'Jb Address�[J}Aryl Alr°/C{�[y CIN Zip ,S,j3 Li pryon ,� �Sr9�� <br /> r ,r V-- — ( --- <br /> Consultant/Sub Cntr Mdly 26UZAddress 7.S� atyS�k ski Lic# 012 Phone# 20 — b0� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> �IEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING#WELL# D OVER-BORE. DIAMETER <br /> PRESSURE GROUT <br /> I<Other G ROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 9 r 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING D14 <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS III H- TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE *USH POINT(GP or CPT)GROUT SEAL PUMPED:r{jYes 0 No (NOTE: MAXIMUO FREE-FAL& DEPTH IS 30') <br /> `SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS J,ZUYf-(,4K- sC2G�su��/ iEiu�,J.o,,. { <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH /001 0 BOLTED YRAFFIC BOX or 0 STOVE PIPE <br /> �// /CONDUCTOR CASING PROPOSED AJ t) (if YES,list specificptiorls in comment section) <br /> COMMENTS:_'&d e_ //t.11-rn( n0 r/tiq � t. e.�� (,I e fJ� , e 4 L! 6/� <br /> � — <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Count OrOrdinances,(Rules and Rpegulationsn,and all applicable California State Laws. 1 ,� A '"'' <br /> Signed x f l„m�_ ,( _ �l =1 /1I Title/Company ��gs� S t / AJ L)6A j6�o <br /> Print Name I Y\ 1 G ' NA 10(k C in Date 8/' I) <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED-: <br /> Application Accepted By / 2�1[U <br /> Date Issued,.- area <br /> Grout Inspection By Date Final Inspection By - fJ�Li., Date .Y. <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> c <br /> 3> 03 FEE <br /> �i 3 SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authori atjen f sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122/04 <br />