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12/29/00 FRI 14:36 FAX Z003 <br /> 12/29/2000 13: 38 209468" '3 FIFTH FLOOR PAGE 04 <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 n <br /> (209) 468-3449 <br /> N NDA Mrt ndfori s YEAR O T <br /> ADPllcation is hereby made to San Joaquin County for n permit to mnstruct seal install Co wort dbacrHee it Thi application <br /> En"Ir is made in complienoi with Sen <br /> Joequln County Development Tltle„Chapter 9-1 115..3 and the Standards of Se /a4 n Co ub�e He>}Ith rv1cFs,Endmnme Aas sloes 19 ?-Xlb -00I <br /> H S r0 f I`”-"�-��If roll Street W Y ZI Parxlif 1 O <br /> WELL Locatlon -d: .7 5-0 <br /> dress- Zip Phone# '��i'�0 �"/ <br /> PROPERTY Owner J / <br /> C-57 Contractor Add City Z`p Lla# '' /' <br /> Consultant`sub Contractor <br /> ri _�Ciry LJc# phonetf <br /> Section <br /> GIS Coordinates:X <br /> y ,Township Ran9a <br /> W 1 To BE PERFO MED: DESTRUCTION(ohaaea tYPe below) <br /> EW w;ELL 1 BORING(CPT.GEOPRt]BE,HVDROPUNCH,HAND-AUGER,OTHER-) D p OVER-BORE <br /> ()SOIL BORING# 13 PRESSURE GROUT <br /> Q WELL it Grout Specifications: <br /> 'Other:_- - <br /> COMMENTS= <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUC N S N (,1 f�. <br /> MONITORING DLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 YES gij+l0STEEL a dWELL CASING p1A� <br /> DEXTRACTION []AIR HAMMER/DRIVEN CASINGTHICKNESSTypEOREMIE'iYPrCAsli TO BE USED: I]au AUGERS 11 HOSE <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL��_ y <br /> D AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: tl Yet: 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q <br /> Q SOIL BORING a HAND AUGER GROUT SPECIFICATIONS! <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH '1A U BOLTED TRAFFIC BOX or570VE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,liar speciFlcelions hcm); <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 t I have prepared this application and that the work will be done in aceordanea With San Joaquin <br /> County Ordina c . Rules Regulations, and all app <br /> llceble California State / rr <br /> TRIG/Company <br /> Signed t <br /> bete •7iQ .�'e <br /> Print Name p RTMENT USE ONLY /Qp-Jso-Co 1/ o0f <br /> r30. 62_:;-� 0Z_ 031 <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: L OD <br /> - I Date Issued <br /> AaprUltion ADCOPted BY, �`- Fnai Inspeetion ey cutc <br /> Grout InSpeclion By Dat <br /> Destrupticn Inspection By Delta <br /> COMMENTSlCONDD'IONS; <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RFG'U BY DATE PERMIT/SrRwo6 REQUESTS INNOICE <br /> 99- 8.1- (/abs I.IK r i 00 002 qS <br /> ochment doc^ 9/27/00 <br /> C-57_ WC_ WAIVER_ C-57 Letter of Authori2ation to Sign permit`Encro <br />