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. 02/13/2001 08:36 20`34683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM . SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> I <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA,, 95202C9 <br /> -� <br /> (209)468.3440 <br /> fjgN!REEUNQML6 PERMIT 9XEIRES 1 YEAR FRAM DATE E'sSUED <br /> Application is hereby made to San Joaquin County for a permit b oonstruct and/or Install the work described. Thle application Is made In compliance with San <br /> Joaquin County Devalopmertit Ule,Chapter 9-11164 and the Standards of San Jbaquin County Public Health Services,EonvironmentaI Heaith Division. <br /> seasaa'6 <br /> WELL Location-pure k. f I cross$treet AR City�IDc.1C�!ln 21p_ T t As Asel# <br /> PROPERTYowner c U� � <br /> E . dress City 2Jp Phone# <br /> C•57 Contractor -_- -- Address City. ,71p`_ Lac# Phang# <br /> ConsukantISub Contractor CLD.1A 141 L Addr9ss_V.ZC` �a.Ud A16S Clty,�y I Lic#Phones` ,'.,�f K�' z�� <br /> • 7„� <br /> QIS Coordinates. .Y .Township Ftan9e SB6tiC <br /> , T-QE <br /> f EW WELL/BORING(CPT,GROPROSB,HYDROPUNCH.HAND-AUGP.R.OTHER*) 11 DESTRUCTION(rmae type below) <br /> Il SOIL 00RIN43# q OVER-BORls <br /> [)WE I7! 0 PRESSURE GROUT <br /> •dlEtas M6f1t�r�r1Y1 V�P , Grout Specicallons;, W . 1tx- , u41I1t:COMMENTS: <br /> ]ME OF <br /> 1 <br /> L I.NSTALLATIONnT CONS'r'tzUcnoN.SPzCIPICATIONS <br /> MONITORING )(HOLLOW STEM "41A.OF BOREHt7LS MULTIPLE CASINGS?11 YES 04I0 WELL CASING DIA: Z'• <br /> Q WIRACTION p Ag HAMMERIDRIVEN CASING THICKNESS E OF CASING: Q STEEL OVC [I MER: <br /> U VAPOR UD ROTARY{Ia'd DE=PTH OF GROUT SEA �� 1�TREMA✓TYPE TO BE USED: a AUGERS NHO$I: <br /> Q AIR SPARGE 0 PUSH POINT ,r„e(1) GROUT SEAL PUMPED; ]'Yes 11 No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> " 101L BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> iT1iEP-_0OTHER APPROX.BORING DEPTH " bo <br /> t.'rEp TRAFFIC BOX or p STOVE PIPES <br /> CONDUCTOR CASING ROP ED? _(If YES,Nst specifications here): <br /> 'CQI4lIIaI>ENTS• W g •11) Z r* W£L(_ Tc) t Sd f W ill 57 i;EL G'r�N�cs+t fv� CA,>t N6 t/yr M t 4o N E ZGr, <br /> OKE N O u,,, —,b #i.( <br /> NOTE: OFPSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 4$WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I here fy that 1 have prepared this application and that the-work will be done in accordance with San Joaquin <br /> Coon Ord[ antes,Rules an lations,and all applicable California State Laws. <br /> Bigned "le/Company <br /> Print Name I AlrJ l 60A( Date V le <br /> ]DEPARTMENT USE ONLY <br /> SITE MAF'IN UNIT IV FILE ADDRESS: ✓-�— <br /> WORK PLAN DATED: V 16 C> � <br /> Ap Uc2Han Accepted ByC)&A , _ _ gate Issue .:I <br /> Q { <br /> Area <br /> CitoutInspedtan 13y Data _ Flnal Inspeollon By Date <br /> Demotion_Insp2don By Date <br /> COMMENTS/CdNCrrms. <br /> ACCOUNTING ONLY. AIDI <br /> FAM <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST 9 INVOICE• <br /> �D <br /> i C-57 WG -WAIVER C-57 Letter of Authorlxatio' to sign permlt.T,,,_EncraachKnent doe 9/27/00 <br />