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MAY-07-2003 14:44 URS CORPORATION <br /> 05/@5/2003 14: 49 ;Gtlyaba. y, ",,,,, 15108743268 P.02i13 <br /> WELL FERMI-r APPLICATION FORM SITE <br /> IGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> FENVIRONMENTAL HEALTH OFp TMCAT952 D) <br /> 304 E.weber, Thl(209)46S-3449 <br /> R M GATE ISSUED <br /> NON-R KUµ AS E PFRMrr"pi application <br /> is mode in 9mpttan�wlftt Sen <br /> Application is hereby made to San Jc aquin County far a pe <br /> mllttoconst-exanCJorfnstallLMeworkdescfbed. Tt+isapp'D�e enL essays <br /> melt Title,Lnapter 917163 and the Standards of Stn Joaquin County Environmental Fie21 "a� <br /> Joaquin Countyl)evelop City ;Tocr4T21p��' <br /> Cross Street 20 114�13 10 0 <br /> WELL Loeatlon eertT r i G 5o ort.WE A t jQCitY Sjg� Z P2 o Fnoneli_� <br /> cress_ g c.n �{ Z o 0 <br /> PfLOPERTYO,yner_ taE °U Lids• G5S GPhOne 91 <br /> CINR �•7 <br /> G-57 CantraGar C to _� AddreSs�g C t(;�� - GNrLiC .�_PhonE Sl0 g9� �0 <br /> warm cNl Adar�ss <br /> 09"JiftBnt r SuD Cantr3Ctor 1„ "'` Range Section <br /> GIS Coordinate:'X <br /> Y TaNnship <br /> p O-StRUCTtON(choose type below) <br /> WORK TO BE PEfiFO� Q OVER-SORE <br /> Z N v�WELL I BORING(CPT,GEOPROBE,HYORORUNCH,HAND-AUGER,OTHER') (�PRESSURE GROLr <br /> �^ B.;OIL BORING# <br /> �'1VcLL� �o;�!SpocifiratlonS: <br /> *C7ther. . <br /> C0)U1b1ENT5: <br /> [NST ! TSN TYQS CONST UCTION SPFCfF►C T1DN5 N WELL CASING(SIA: 2 <br /> TYPE OF WELL �� M, TIPLE CASINGS?a YES 0 <br /> DIA.OF SOREHOILE� F VC p O-NEP <br /> MONITORING 1$HOIt� "'YPe OF CASING: n�EEi, I� 40SE <br /> Il i 10 (�AIR FiAMMER1DRNcN CASINIZ HICICNFSS� <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEA'-� �.TREMIE T lPE TO 6E USED: 0 AUGERS <br /> SPARGE (]?U:iH POINT uROUT SEAL PUMPED: l�Yes Q No NOTE: MAXIMUM FREE-FALL-L bEpTH lS 3f)') <br /> 11 AIRS GROUT SPECIFICATIONS; <br /> {SOIL BORING C HAND AUGER o BOLTED TRAFFIC 90X ar $STOVE PIPE <br /> a OTIiER�.--,- �7OROX,60R1NG D2?-FI„tfQ T �� $f YES'list SD£cifi=tions h6re):_ <br /> O"fHER:_----�-- CONDUCTOR CASING PROPOSED? <br /> NOTE: OFFSITE BORINGS REQUIRE A SCN O ADVANCE FORALL�AD�QU RED INS PLL, IONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOUR <br /> I hereby Certify that I hap prepared this application and that the work will be done in accordance with San Joaquin <br /> s tion5,and all applicable California State Laws. <br /> p'�ReulaCounty Ordinances, piZoGG <br /> 7%elCompany <br /> Sgned - ENT date <br /> PrintNama NLY <br /> DEPARTMUSE O <br /> SITF_ MAP IN UNIT IV F11E,ADORES$: <br /> WORK PLAN DATED' <br /> Dat:Issued_ <br /> Application Accepted 13y Date Fnel Inspection By <br /> Grout Inspection By <br /> Destruction Inspection BY Date <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# rerye <br /> Plc CORES FEE INFO AMOUNT REMITTER CHECK it REC'o BY DATE PERMIT ISERVICE REQUESTI fNVOICE <br /> 1125/ <br /> C-57WC__ W/tIVER— G-57 Getter of Authorization 1'o sign permt iEn-CrCOChment doc <br />