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12/07/2000 09:52 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS=Ei-10) <br /> 304 E. Weber, Third Plots, Stockton, CA., 95202 <br /> (209) 416$-3449 <br /> AEON.REFUNIDA LE PERMIT E C�E81 YEAR FROM QATE 154UE[ <br /> AppalcaWn i$h*MbY Made to S*n.ioaquan County for a permit to constmot 2ndEr install the vmrk desodbed. This aPPiicawn is made to e0mpaianc�wtttr San <br /> Joaquin County Devetopment Title,Chapter 9-1115.3 2nd the Standards of San Jo24uIn ffty Public Health Se ' 9,Environmental health 0ivtsion. <br /> A88e890r 20 r TT 0AW <br /> WELL Locatla Y -dross Stre@t City p ParG�eliA w <br /> 3�1a <br /> PROPERTY Owner Addrsssra) We City yae�Zpal'0 p h a n a <br /> 704 <br /> c-6"t re dross PC _G Sy►°Lzp��`.S�f2.5' orte# <br /> Consultantlo Contra 1J.�-L-C -- Address ✓l Ci[y��1i3►+>�_.Lidf� �Phorte#�D� 28��30 yo <br /> GIS Coordinates:X Y _.,Township Range Section -- <br /> WORK.M BE. <br /> (NEVV WELL I BORING f CAT.GEOPROBE.HYDROPLINCHi HAND-AUGER.010ff *) q D�I•�tt1CTIQN I#+ootetKpe 66�) <br /> U SOIL GORING# _._l 0 OVER-SORE <br /> )OWE:LL# G:k� r-I►�(3YI i-6vI YI p pRESSURE GROUT <br /> .��r; _ C/ Gresut S ficaYrons: <br /> COMMENTS: <br /> TYPE OF WELL N T LkMI N TYP C ^A d l l <br /> MONITORING HOLLOW STEM ENA.OF BORF-HOLE - MULTIPLE CASINGS?(I YES' 1�,NO W{3LL CASING DIA: <br /> r0 EXTRAr-' lON U AIR HAMMERIDRIVEN CASING"►HICKNESS ��C)Z-��TYPE OF CASING: 1]STEEL iC [I OTHER: <br /> []VAPOR [}14113[?ROTARY IaEPTH OF Cyl Ot17 SEAL TREMIE TYPE TO BE USED: AUGERS (�Mt75E <br /> [)AIR SPAROr; a PUSH POINT GROUT SEAL PUMPED: es Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br /> fl SOIL BORING D HA.a40 AUGER GROUT SPEOPICATtON5: e-HW 1 . slk&,(01:4e <br /> a OTHER; U OYHER -. -_ - APFROX_BORING DEPTH I-N )(BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSE-01' 2_(if Yf'"B,fist speaTlcations her+�):,.„ <br /> *CC1MMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS Qin ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 43 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be dune in accordance with San Joaquin <br /> County O inances,Rules and Regulations,and all applicable Callforlrila State Law& <br /> X _`o .�.-- TitteJCOmp2rly EM � t f• <br /> Print Name Sf c l� ... Bate- a 0 L -- - <br /> _ -D' MUM—ENT U$E-NNL1r" <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Apgtiastion Accepted BY �• ' • V v Dete IsauM_jj ` Area <br /> f3reut Inspection 8y Final Inspaction By Daft$ <br /> Destruction Inspection 13y Date <br /> COMMENTS/CONDITIONS. � <br /> ACCQUrJTING ONLY: .RID# FACA <br /> PE CODES FEE INFO AMOUNT REMI I I D CHECK# ItECID By DATE PERMIT 1 68RV5CE REQUEST# INVOICE <br /> 3 5 0 <br /> C-57 WC -WAZ1lEI _ C-57 Letter of Auth oriCsign per mit Encroachment dot- 9/27/00 <br /> f, <br /> v <br />