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12/29/00 FRI 14:30 FAX am <br /> 12/29/2000 13:38 2094533 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 (PMS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 A ' 6-4 <br /> N - NOA MIT EXPIRES 1 YEAR F T 0017- <br /> N <br /> 0 l 7-3�ck5 <br /> Aopllcatten is hereby made to San Joaquin County}ors permit to construct and/or install the work described- Th application is made is compliance with San <br /> Joequln CountyDevelopmanttltle„Chapter9-11153 and the Standards <br /> �ofjof San ubllc He th rvices,Endronmentml Hoeft Division. •� <br /> (�,� �{/N-r� W y A98EssPrs '(�Q-1 I -00 5 <br /> WELL Lo tlan �vN S I-O P ross Street 21p ParcelN 1 D I” <br /> 17 �a1 5� _� i�.�a <br /> PROPERTY Owner cess � I Zip <br /> C-57 Contractor Add city Z p LIoiF •�r�'7P� _ z <br /> Consuftantl Sub Contractor mss - _ City C- ,,Il­Uc# Phena6—mqjL��- <br /> GIS Coordinates:X ,Y ,TownShiP Range Section <br /> E PERFO ED. <br /> EW urELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") D (chooss,type <br /> g SOIL BORING K g PRESSURE GROUT <br /> g WLLL it_ <br /> •other: Grout Spodfications; _ <br /> CDMMENT5: <br /> TYPE OFWELL //''T''A TYPP CONSTRUCT/ V <br /> MONITORING DLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?g YES 911 WELL CASING DIA' <br /> g EXTRACTION B AIR HAMMERIDRIVEN CABINGTHICKNESS TYPE OF OASING: nsTEEL T{VG /]OTHER: <br /> g VAPOR B MUD ROTARY DEPTH OF GROUT Sli t(O TREMIF TYPE TO BE USED: g AUGERS n HOSE <br /> g AIR SPARGE g PUSH POINT GROUT SEAL PUMPED: U Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') 0 <br /> n SOIL BORING 0 HAND AUGER GROUT SPELIFICATIONS: <br /> d OTHER' n OTHER APPROX_BORING DEPTH -g BOLTED TRAFFIC BOX or7OVE PIPE <br /> CONDUCTOR OASING PROPOSED? (if YES,list spec5hoabona hero): <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. p <br /> I herrby celTlfyave prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina c Rules RegulationS, and all applicable California Std Law-A. <br /> Signed Ttla/Company ' �. F� �/ <br /> Date 7/ <br /> Print Name PAIRTMENT USE ONLY <br /> /Q8-7a.o-cell oof <br /> r30. 6 OZ-3 03/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S c <br /> WORK PLAN DATED: L OD / <br /> �,,,��},( Oate Issued I 'l � OO Aroa 03 <br /> Application Accepted Pete <br /> Grout InSpection By Dat• Final Inspection 15Y <br /> Destruction Ins acdon By Date <br /> COMMENTS 7CONDRK/NS; S M au eq— <br /> ACCOUNTING ONLY: AIDA --- <br /> PE CODES FEE INTO AMOUNTREMRTED CI4ECKS lgi BY DATE PERMIT I sliRVIOE IEQUESr4 INvpICE <br /> C-57_ WCWAIVER_ C-57 Letter of Authori8dtion to sign permits. Encroachment doc� 9/27/00 <br /> C <br />