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an Joaquin County <br />mental Health Department SITE <br />Ax117 301 Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 4 t Fax: (209) 468-3433 Web: www.Sigov.org/ehd <br />rvviRONrt N - UNIT Iv <br />NERW�SERVICF II 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 />Assessors <br />WELL Location I04 -c- �t7¢s�-rip ,�tE ross Street 1`4�"Uk U0 City i cel Zip 1 G � � Parcel# <br />PROPERTY ? <br />Owner6LIt�Akt{k-t i 3V Address % 7� �' h,JSTf�t�1t City 5(n`a�(_A{2L: �� Zip` UVIO Phone#��) S716 -&15-0 <br />C-57 Contractor6' (-'LC,, a i�tz �C i:t iL� Address'/3c +i � urs- ✓ •J City f i nl0i-2 Zip 1*> J l <br />5 Lic# i✓S Phone# 31.� CXR <br />Consultant / Sub Cntr(:hMZy2t+k "ti A-­r-Mddress5`/='Z' ri:LL+"a -It A Cityf&tt Vt,? Lic#Phone; ,5-16 o - c Oc <br />GIS Coordinates: X -'Y Township Range Section <br />WORK TO BE PERFORMED: <br />NEW ELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') p DESTRUCTION (choose type below) <br />SOIL BORING # - [] OVER -BORE. DIAMETER <br />WELL # [] PRESSURE GROUT <br />[]'Other GROUT SPECIFICATIONS t <br />1 f �,c.�� <br />COMMENTS: >` ]}�,; �,n-�1�Se�\� �3 c# �a�".:�v kti��-.r 1r,�lkM' 1. Se''FkIJ�f�Sl �O <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />V+tir % MONITORING HOLLOW STEM DIA. OF BOREHOLE- 7�" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />[] EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL VPVC 0 OTHER: <br />[] VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS [] HOSE <br />VAIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes + (No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />. t�f SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />[] OTHER: [] OTHER APPROX. BORING DEPTH :�, , BOLTED TRAFFIC BOX or [] STOVE PIPE <br />r�,, CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: `��tiv*� ;�-yj ti_ L:•iiC I 10 {1 L <br />1t ./ S Of �t ,+? ii��3v to I eut <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />I hereby certify that I have <br />Count vOrff fin—a—n-de s, RuIei <br />Signed <br />Print Name <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />this application and that the work will be done in accordance with San Joaquin <br />ulations, and all applicable California State Laws. <br />Title/Company S,, <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ) d 2 2- Fro n iGa C- -E0Q l <br />WORK PLAN DATED: M <br />Application Accepted By %/; G+L) rid L t r I C 6a r fns Date Issued 8 $ b $- Area <br />Grout Inspection By %ee+afia M116y+Agger Date 8- l S b S Final Inspection Byyl o-oy; ¢ Date <br />Destruction Inspection By Date <br />COMMENTS/ CONDITIONS: of MW -ID and A S-1', q>-jd i7!]1(nnr r»erL�C) "18 <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST <br />I�IVOI�E <br />350 2G9.00 <br />'' 3G8. o <br />SR# oo43+46 <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 />