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09/28/2001 12:13 x'2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEtRVICES UNIT IV <br /> Sr P 2 0 2001 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 344 E. Weber, Third Floor, Stockton, CA., 95202 <br /> E;��rI- �i tier _Ff l hrl�Ll i {209) 468-3449 <br /> ur <br /> 3+1ON.REF' WABLE PERmrr ExF4RES 1 YEAR FROM DATE ISSUED <br /> Applicabon is hereby made to San Joaquin County for a permit to construct anNor install rework described Then application is made In coTguance with San <br /> Joaquin County Development Title, <br /> 'hapten 9-1115 3 and the Standards of San,ioaquin County Public Health�er►+tires,Enyronmental�Dwiso�ssion <br /> WELL Locatlan 4 (,ene c Cross Street & City rAz, kA : Paraei#, At' 6P Z9- <br /> PROPERTY owner 771e � AfJdress 29 or F .� ity. 1a�d zip phone#E'2 � �/ <br /> G,�A. z 9 I #71007f Pthorw 7 OO <br /> c-57 Contractor �../!,l Address G.1 6 Crty�. - per / <br /> Consultant I S actor l� Address 1 `*' Clty�— dx SI Phoned 6 S <br /> G IS Coordinates X Y ToNnship !�Al Range_,_ _SscbOn .2 / <br /> WORK TO Be PERFORMEDESTRUCTION(dhoose type 1�elarr) <br /> p NEW WELL/BORING(CRT,GEOFI20BE,HYDFtOPUNCH,RAND-AUGER,OTHER-) (]OVER-BORE <br /> a SOIL BORING# J'PRESSURE GROUT <br /> 11 WELL# Lc+ly <br /> *Other Graft SpeaFcadions_ � •FeC�f�.k eW c,.,14S°Y Q.A PA -- <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING d HOLLOW STEM DIA OF BOREHOLE MULTIPLE CASINGS?p YES p NO WELL CASING DIA <br /> �lCTRACTION a AIR HAMMER1DRrvEN CASING THICKNESS_ TYPE OF CASING 13 STEEL p PVC 0 OTHER <br /> (l VAPOR p MUD ROTARY DEPTH OF GROUT SEAL <br /> TREE ilE TYPE TO BE USED p AUGERS a HOSE <br /> 0 AIR SPARGE fl PUSH POINT GROUT SEAL PUMPED 0 Yes B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> Il OTHER 13 OTHER APPROX BORING DEPTH 13-BOLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specrflcadions there) <br /> 'COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALLTHE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this appiicatlon and that the work will be done In accordance with San.Joaquin <br /> County Ordina s,Rules and Regulations,and all applicable California State L�iws. <br /> Sagned x <br /> Titie'COmpany (/,t? G 10�•�++ s.., <br /> Dade <br /> Pnrht Nameee� °efle DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ZS <br /> WORK PLAN DATED: <br /> Data Issued UT <br /> Application �d� Date Final Inspection By_j e�----- <br /> Groutlnspec9an sy <br /> iligirtrticbon Inspection By Date <br /> HtMENT8 f CONDITIONS* <br /> ACCOUNTING ONLY AID# ' � <br /> PE CODES FEE INFO AMOUNT REMrrTfiD CHECK* REC'D BY DATE PE <br /> LRMIT I SERVICE REQUESTS INVOICE <br /> i q <br /> - <br /> rrnjt <br /> r-R? Wr -WATVFt7 r-ri7 I st}or of Aisthnrt7n+i n to clnn noi=n�rnnrhinon�.for <br />