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0`2/13/2001 08:366 2094683433 FIFTH FLOOR PAGE 02 <br /> r <br /> WELL PERMIT APPLICATION FORM <br /> w" SITE <br /> SAN J[3AQUIN COUNTY P MITIGATION <br /> E PUBLIC HEALTH SERVICES UNIT IV <br /> NVIRONMENTAL HEALTH DIVISION (PHS#EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA.,95202 — <br /> (209)468-3449 <br /> NON-RPFUNDABLI=PERMIT EXPtR B 1 YEAH FROM DATE 1SS= <br /> I. 4901catlan Is hereby made to San Joaquin Courriy for a permit to construct andkr install the work dsscaibed. This applioatlon Is made In eomplianva with San <br /> Joaquin County Davelopmegt Title,.Chapter 8-1116.3 and the Standards of Sari,lbaquln County Public Health Services,Environmental Health Divlslon. <br /> t;>or�n'r� <br /> WELL LoCatien �}P tri, Lir Cross Street �}��^ t �[r�f arceaspr's <br /> S F{7���- 4r Ip�„TrParcef# <br /> ee <br /> r�k 5 k" <br /> >ROPERTY Owner � . '+nAOdress t. M11City She 2jp Lr31AZ Phone# Z j 3 <br /> CSfCantraoto r ('Tura^ ddress J CityMah�l.tP211nLic#45---4yr�7 Phone# - i3�S";c <br /> :onsultAnt 1 sub contractor,Q42 IJ 011t - Address vim: cltyOQ1C(f uc##�hone#�,!�z � y z JE� . <br /> �I$Coordinates: Y2� <br /> .Tavmshlp Range Seal <br /> T E P FpRkII-C401 )GEOPRO80. <br /> EW WEI.l I t3OR NIG HYDROPUNCH,HAND AUGER.OTHER*) p DESTRUCTION(dWase type be" <br /> SOIL BORING 0 Q OVER-BORE <br /> -Gti►e d WELL# r4ut8pedflcati0n5;,. 0 PRESSURE GROUT <br /> r. G <br /> j ',OMMENTB: - <br /> TYPE QE WEL INBTALIATIONTYPE C01M3UUGT-gN.SPECIFI04riQN5 <br /> q MONITORING ji HOLLOW STEM 'DIA,OF BOREHOLE_ _ ---__MULTIPLIZ CASINGS?II YES JI NO WELLCASINO DIA: <br /> EXTRACTION it AIR HAMMERIORIVEN CASING THICKN TYPE OF CASING: Q STEEL p PVC Q OTHt'sR; <br /> aj VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> n AU(3ER8 U JOSE <br /> a AIR SPARGE 0 PUSH POINT GROUT SE&PUMPED: Ares Q NO (NOTE;MAXIMUM FREE-FALL DEPTH IS 30') <br /> L BORING p HAND AUGER ORovr.SPECIFIdAT10N8: _ <br /> .I u l"HER• o-rHER C ET APPROX.BORING Dt_PTH J f D' _0 BWEV TRAFFIC SOX or (j STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? ..D0Q_(if YES,list spedfications here): <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 qertjy that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County 0"naVes,Rules anj Reg ns,and all applicable California St a Laws. -f <br /> `'tgnedTlaelcompany ►� <br /> Print Name <br /> DEP TME.NT USE O LY <br /> SITE MAP IN UNIT IV FILE,ADDRESS; 1 U2, h Q r <br /> �WORK PLAN DATED: <br /> AMIlleaSon Accepted ey 0 Lo r STfzlzxl^ „pst9 Issued O I Ares <br /> Grout Inspection la DatO Final Inspedon By Date <br /> *M04on Inspection By — Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY.- AID# <br /> ,ODES FEE INFO AMOUNT REMI TED CHECK# RECID MY DATE PERMIT/SERVICE REQUEST INVOICE <br /> , :, <br /> '-57' WC -WAIIIER,— C-57 Letter of Authorization to sign permit_Encroachment does_ 9/27/00 <br /> cpt- 'gr 11, <br /> 7- ` <br />