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Feb 26 01 03: 41p F ctrum Exploration, Inc 2( 465-8773 p• 3 <br /> FIFTH FLOOR RAGE 03 <br /> 02/26/2001 15:15 2094663` � DMINAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED !kation is made in compliance with San <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This app <br /> Joaquin County Development Title,Chapter 91115.3 and the Standards of San Joaquin County Public Health Services.EnvironmentaleHea Health Division. <br /> ��� /fir <br /> � 7-V S7— � ��City Zip Parcel# Q+� <br /> WELL Location � a Cross S�tre)et��������'—'-_ <br /> Address/ �/ �O� City ZipL sem_ hone# <br /> PROPERTY Owner / N" <br /> Ciry Zip Lic# Phone# <br /> C-57 Contractor�i 2 t Address p�7/� <br /> Consultant I Sub Contract /kAddress <br /> Ity�,_Llc#.Sla2t'e8 Phone O <br /> Section <br /> GIS Coordinates:X Y <br /> Township Range <br /> W RK TO BE PERFORMED: Q DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPFWOI <br /> PROBE,HYDRO NCH,NANO AUGER.OTHER) a OVER-BORE. <br /> Ilrr\\ RING#._ PRESSURE GROUT <br /> L BOELL if <br /> Grout Specifications: <br /> *Other;— <br /> COMMENTS: <br /> TYPE OF WELL �103AIR <br /> TION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?a YES a NO WELL CASING DIA: <br /> TYPE OF CASING: a STEEL a PVC a OTHER:— <br /> Q EXTRACTION HAMMERIDRIVEN CASING THICKNESS— TREMIE TYPE TO BE USED: O AUGERS a HOSE <br /> It VAPOR []MUD ROTARY DEPTH OF GROUT SEAL N NOTE:M IMUM FREE- ALL EPTH 3 30' <br /> PUSH POINT GROUT SEAL PUMPED: a Y a /vd <br /> a AIR SPARGE a � J <br /> OIL BO a HAND AUGER ROUT SPECIFICATIONS: <br /> �° a BOLTED TRAFFIC BOX(4r a STOVE PIPE <br /> N]OTHER:&a OTHER-----' APPROX_BORING DEPTH <br /> l" o if YES,list specifications here): <br /> CONDUCTOR CASING PROPOSED. t <br /> *COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALl REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have preps tationsPla dtlall app cable California dStte done in to Laws. accordance with San Joaquin <br /> County Ord s,Rules d egUl /-jC. <br /> Title/Compan <br /> Signed x Date <br /> ��0� <br /> Print Name DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. / <br /> WORK PLAN DATED: r <br /> Date Issued �_ 1,C),0 �—=-- <br /> ApplicaUon Accepted By Date 40/ <br /> / Final Inspection BY <br /> Grout Inspection By J Q <br /> Date <br /> Destruction Ins ection By <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AIDfI <br /> RECO BY DATE PERMITlSERVICE REQUEST>Y INVOICE <br /> pE CODES FEE INFO AMOUNT REMITTED CH ECK# 2'23 007,5 <br /> 2q t/ 4•— �Jr 9/27/00 <br /> C-57— WC;WAIVER-- C-57 Letter of Authorization to sign permit Encroachment do <br />