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06/19/2000 03:30 925-463-2559 'ATC PLEASANTON ,, ,PAGE 02 - <br /> Ub/14/'Ldb1 19:13 2094SE 3 FIFTH FLOOR r, i PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> TION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT Mt71GIV <br /> AA <br /> ENVIRONMENTAL WEALTH DIVISION (PHS-EHD) , <br /> 304 E.Weber,Third Floor, Stockton, CA, 95202 65 G1 <br /> (209) 468.3449 SIZQ l7 <br /> NO6 EFU DABLE PERMR ErtPIRES 7 YEAQ FROM DATE ImmU <br /> Application Is hereby made to San Joa4uln Caunty for permit to construct andlor.insto the work described.This application is made in cwmplisrtce with San <br /> Joaquin County Develo ent Tine.Chapter s-1115.3/and,the Standards off San J,o*4diiinC_ounty PPuuolic Health Services,Encircnment*l Health Division. <br /> WELL Location 3���m�e�G� Cross Street���[��/�+'f�jCfty✓� � 2p �/.�,�Parcal$ ������aOp��[�1 <br /> PROPERTY Owner ,,/(�Q /ya„rfAyor�•/"/”! Addy25Qs �� ,��y /� '—City � /� ^��y�p.A<—=Pnonei✓=~ ��p n yt <br /> C.57CantractorT/7Wf `��rii�i7� City& 7vtA-�IJdi�home$011�7' ec'✓✓T <br /> ,�T�, oc. Address(O6r�l�l�B//se ' city _ phbn6#�GT - 60 �D <br /> ConaukarrL/Sub Contr7cbr /p <br /> GIS Coordinates-X.,Y .TownshlP,- Range $0etidn O <br /> WORK TO BF-PERFORMLD: p7 DE UCTION(choose type below) <br /> p NEW WELL/BORING(CPT GEOPROBS,HYDROP}}��,,NCM,y GER�T E 0 <br /> t7b� PRES�BORRE GROUT <br /> ,�v� <br /> QWELL a <br /> Grout SpeCifiCatiOrhs' <br /> COMMENTS_ <br /> TYPE OF WELL INSTALLATION TYpE CONSTRUCTION SEFC113GAT10N.S <br /> p MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?D YES ONO WELL CASING DIA <br /> 0 EXTRACTTION I]pJR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING; 0 STEEL 0 PVC p OTHER: <br /> G VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE p PUSH POWT GROUT SEAL PUMPED: p Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> O,SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER:.0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or U STOVS PIPE <br /> CONDUCTOR CASING PROPOSED? i If YES,Gst specifications 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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> 519ned x GO%{'�/�y TllelCompany f7'�L $OC• <br /> �/GRi� �'�SGOD.G� - Date <br /> PrintName � <br /> �DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD SS: <br /> WORK PLAN DATED: 6 <br /> Data IeoYed � ���� Ar Zy � <br /> Apprcahon Accepted By Date <br /> Grout Inspection By Date �inat InspeCtion By <br /> Destrudon Inspection By Date <br /> COMMENTSICONDtnON6 <br /> ACCOUNTINGONLY: AID# <br /> PE CODES FEEINFO AMOUNTRBMITTED CHECKS RECD 6Y OATC PERMIT IBERVICOREQUl-S S INVOICE <br /> 7T0-7 Zq o G:;)06 s6 <br /> t encroachment doc� 9127/00 <br /> C-57___„ WC ✓`iNATVER G-571-ettsr of Authorization to sign permi <br />