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SEP-19-2000 15:51 FROM "'RECISION SAMPLING TO 12094683433 P.02 <br /> 0 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUINd COUNTY PUBLIC HEALTH SERVICES g rTIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) UNFT IV <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> a (209)488-3449 <br /> aot+l4MFuktv0t.rE MEM MWIRiES ti nntEM PAWL <br /> Application is hereby made to San Joaquin Courtly for a perp i t to cons>tict andfor install Sm work described. Thin appicatioa)s maLka in compliance vhth San <br /> Joaquin Gbuniy Development TA18,�C�hrapter x111„5�8.a►n�d,,th��xStaird&rdE of n Joagtdrt County Pubt�icr Health SerWcw,En itommentpl Health division. . <br /> �04 <br /> WELL Locadm /6�• �t�r�'!�+�Ira ss Street ��'/�parzet# a <br /> PROPERTY Ovmt.:s <br /> ��. SOL ,�y�Cit/y zI 9j !Phon,o_.- <br /> CSfContradorrcr1 Address P/00S yl�4l`�`/ City )�� gLlo Phone ��) 7-`�<75 <br /> Constrtdtnt 1 Sub Corso-act Address Y lkft rphone# <br /> MS Coordinates:X Y Tawnsltip Range _ Seatlon _ <br /> WO <br /> % Be URELUMEM <br /> Q NEW WELL I BORING(CI' , PROBE,HYDFtOPUMC NAPID-AUGE .OTHER1 0 DESTRUCTION(choose type velar) <br /> SOIL BOE21htG � = LZ'&I rl OVER-BORE <br /> ELL u a PRESSURE GROUT <br /> 10mr: GROUT SPECIFICATION_--_ <br /> COMWNTS: <br /> =OF WELL INSTALLATKIN TYPE CONSTRUCTION 8Pr_CIEWIQNS <br /> 11 MONWORJNG Il HOLLOW STEIN DW OF BOREHOLE__MULTIPLE CASINGS?0 YES n NO WELL CASING I)W <br /> I]EXTRACTION 11 AIR HAMMERCRIVEY 0AS;NGTHICKNESS TYPE OF CASWGz U STEEL 11 PVC 11 OTHER: <br /> 0 VAPOR Xmm <br /> {1UMUD ROTARY DEPTH OF GROUT SEAL TREMA=TYPE Tfl BE L1a�p; 11AUGERS IIHOSE <br /> I1 AIR SPARGE PUSH POINT GROUT SEAL PUMPED: DYos nNo (NOTEMAXIMUM FREE-FAL.LDEPTH1S3(Y) <br /> 11 SOIL BORING AUGER GROUT SP'SCIRCATION <br /> 0 OTHER:_, Q OTHER APPROX.SORYNG DEPTH `0 BOLTED TRAFFIC 60X or Q STOVE PFE <br /> CONDUCTOR CA.StfOG PROPOSED? (if YES,Bst spocftatione hero): <br /> CEMENTS: � ��� CILCQI"� � <br /> NOTE: OFFSITE INGS REQUIRE ACCESS ENCROACH �ENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in neeordOnCa With San Joaquin <br /> County Ordinances,State taws,and Rules and Regulations of the San Joaquin County. <br /> L THE UNLIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> Slgred \ ( c r Q re u 5 4 TitWOampany�T r✓1 /�G. i rt7 riy� <br /> P”N S/��y�^. ...._Ogle— <br /> 7-- <br /> .^� <br /> SITE MAP JN NITffif CILE ADDRESS IWORK PLANT DATED <br /> DEPARTMENT ONLY <br /> l+pRkcation Accepted 8! Clete issuedO <br /> 7.49T 10 8 <br /> Grout lrexpeetlpsl By _ Date. Final lrmpa,3Oon By Da — <br /> Daah#Won Inaoectim By pate <br /> CMMENTS t CONDITIONS- <br /> RCCOUPMNG ONLY: A)DO <br /> FAM <br /> Pts?cams FEE ANIFR ALMUNT REMITTED CHECK A RE"RYDAIjIE : <br /> PE <br /> Ka6ff I SET{yICE R1;QlIE T 9iNVC)1Gt? <br /> C-57„_,_,_ YVC1WA-1VER C-57 Utter of Eluthoriza.tion to sign perrnit__Encromhment doc 9I12f00 <br /> G8 2SV1=1 annn_j ui AT_j --..------- <br /> TOTAL P.02 <br />