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07/25/2001 15 59 2094683433 FIFTH FLOOR PAGE 03 <br /> 10-24-2000 03 t 40PM FROM TO 153W766005 P.82 <br /> WELL PERMIT" APPLICATION FORM SITE <br /> lie SAN JOAQUIN COUNTY PUBLIC HEARTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EI-HD) UNIT IV <br /> 304 E.Weber, Third Moor, Stockton, CA-, 95202 <br /> poo) 468-3449 <br /> MON REFUNI1.4131-1=PERMFr EXPIRES 1 YEAIq PROM;ATF-LSSUED <br /> AppikAdon is hereby made to San Joaqutn County Ear a perlmt to construct andlor install ipe work dwcnbe3 This applicator)Is made,n compllwv=with Sen <br /> Joaquirt courtly asvelopment Tttie,Chapter x1115.3 and thB Srandarrt r,of San Joaqum County Public Hesith Services,Ernnrattmenug Health ommions <br /> r _ �. � <br /> WELL Lvedtfon i� < 1 r r� � Gross Street C�1 s��r �Cty S7oe� � �p�.3.2o�xt <br /> PROPERTYOwneF� Cr7..z 4� 151N., ddress foCity fl�C, tJr zip�v��e Pt,or�el: o4�r'3?-&37 <br /> C-67 Contractorod W a.'_ crass po¢ox .3 3 6 �C,nf��F�a LGA 7 a6y ori 7fa7 37��Y3uo <br /> Consultant!Sub Contractor lQG d�. J1r�.,wce+ dtsss <br /> G1SCaerdmatm'X Y Township Range S=on <br /> r <br /> WORK TO8E F M D <br /> kRWW W�L f 5OR]NG(CPT GEOPROSF-HYDROPUNCH HAND-AUGER OTHER41 Q D-:STRIx7T1oN lehoosd type'below) <br /> 0 SOIL BORING 9 p OVER-BORE <br /> W-N ELL#�? LA)- 6At 0-4+A9 0 PRESSURE GROLrr <br /> rpt}, ; _- Gro�.it Spa�6cat+ons <br /> COMMENTS <br /> 'Y'YPE QF 1141Ft t INSTALLA710N TYF+E CON STRUCTiom SPECIFICATIONS <br /> kMONITORNG (104o -0w STELE DIA OF SORGHOLE Sr MULTIPLE C. SINGS"U YES eMNO WELL CASING DLA2/t <br /> 0 EXTRACTION 1:]A R HAMMERfDR SEN CASING THICKNESS-le-LY-0—TYPE OF CASING' p STEEL Xtr!G 13 OTHER­— <br /> vt>pora MUD ROTARY oepTH bi GROUT SEa O TR.Em,E TYPE 7"Q W USED- XUGEFM 3110SE <br /> 6 AIR SPARGE I]PUSK POINT GROAT SE=AL PUMPED jgS' 13No (NOTE: MAXIMUM FREE-FALL DEPTH IS 34') <br /> 13$OIL BORING 13 HAND AUGER GROUT SPECIFICATIONS- Ale-7- ag,"A d <br /> 13 OT14mk _ O OTI iER_ APPROX.BORING DHPTH D e80LTED TFaFFIC Bax or U STOVE PLFIE <br /> CONDUCTOR CASING PI20POSEOo p_(IfYES.Fist specaicallone here). <br /> -co1lIME�Y"i'S �. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNrT IV INSPECTOR 48 WORKING HOURS IN ADVANC5 FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accords noe with San Joaqutn <br /> Cotinty Ord noes, Rules and Regulations,and all applicable Calfforrua State Laves` <br /> Signed x 'S A N Inge/CompanY <br /> Print Name S L ,n rr _Dat', <br /> QEPARIMENT USE ONLY <br /> SITE MAP IN UNrr IV FILE,ADDRESS: IZAa <br /> WgRK PLAN DATED: <br /> APpil ation Accepted ay Date Issued_ <br /> Grout Inspec5on By Qata Finat tnSpectian Br patte— <br /> DeSt U5O on InspeUmn By Date <br /> COMMENTS f CONDITIONS <br /> ACCOUNTING ONLY AID„ <br /> PExCODt S FEE INFO AMOUNT SZ5MiTTED CHECK# RECD BY DATE' PERMrr 1 SERVICE REQUEST A WVOIC3 <br /> C-57— Wi -WA1:VFP_. C-57 Letter of Authamrdtion to sign perttr it Eneraachment doc� 8/27/00 <br /> TOTEM.. P 02 <br />