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7/2000 10:42 204683x33 o FIFTH FLOOR. <br /> PLICATION 7E <br /> WELL PERMIT APr:+uc <br /> FORM S► <br /> /r - � MITIGATION <br />/ SAN JOAQUIN COUNTY PUa BLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E,Weber,Third Floor, Stockton, CA-, 95202 <br /> (209)468-3449 <br /> NON-REFUNDABLE P RMT EXPIRES t YEAR F OMD YE ISSUED <br /> Application Is hereby made ro San Joaquin County for a penult to Construct;nd/or install Me worK described. This application is made in compliance witf,San <br /> Assessols ( _7 <br />�,. Joaquin County Development Title,Chapter 9''1115.3 and the Standards of San Joaquin County ith Services.S �ePzr�!#alih Division <br /> �. Cross Street d� ih City n. <br /> WELL Location .� ) -I lirGl",. .t-Cr LpQ/,�-�PhoneA` <br /> . r" ` nn [�,,..r Utiri• City q$L3, -- <br /> Address r <br /> PROPERTY Ownerot0. .. iUtZzo9aYPhoneu(ri/6)7T �?"y100 <br /> C.67 Contractor i lii l,�i _ -�� •" Address Q. <br /> 1, LiC# Phone#(1rV)AY�32. <br /> Consultant I Sub CoNrador_rc c�(mn AI U Address Q N i JSic 5.31$City�O_1 <br /> _ hRan90 Section=�. <br /> . Township <br /> GIS Coordinates:X •Y—�'i - . �Y <br /> .`,. ".•-"._ DESTRUCTION(choase typa'Delowl <br /> WORK TO BE PERFORMED: {3 OVER-BORE <br /> NEW W ELL I BORING(CFTDGrEEOIL BORING#ROPUNCH.HAND-AUGER.OTHER')• U PRESSURE GROUT <br /> , WELL 0— Grout SPedfioatlons: <br /> •Other. <br /> TYPE OF WELL '^"'INSTALLATION TYPE.,.. CONSTRUCTION SPECIFK:ATIONS <br /> MULTIPLE CASINGS?DYES U NO WELL CASING DIA:�� <br /> 'MONITORING'- --•- HOLLOW STEM.w. -DIA OFBOREHOLE TYPEOFCASING: pSTEEL UPVC ❑.OTHER: <br /> U EXTRACTION OAIRHAMMERIDRIVEN CASING THICKNESS <br /> ARTREMIE TYPE 70 USED: U AUGERS (]HOSE <br /> 0 MUD ROTY DEPTH OF GROUT SEAL <br /> Q VAPOR GROUT SEAL PUMPED: U Yes 0 No (NOTE: M <br /> AXIMUMM FREE-FALL DEPTH IS 30') <br /> 13 AIR SPARGE aPUSH POINT, <br /> OSOILBORING 0HAND AUGER GROUT SPECIFICATONS:- <br /> APPROX.BORING OEPTH��- BOLTED TRAFFIC BOX er Q STOVE PIPE <br /> .11 <br /> 0 OTHER: OTHER ? (if YES,list specifications here): <br /> CONDUCTOR CASING PROPD$ED. <br /> •COMMENTS: s <br /> HMENT <br /> NOTE: OF VSN a BcOroRN48 REQUIRE <br /> HOURS IN ADO Cloll <br /> E FOR AL CREQU RED NSPEC7510NS. <br /> CALL THE UNtI _ <br /> o .. <br /> red this application and that the work will be done In accordance with San Joaquin <br /> 1 hereby certify that I Ill reps <br /> County Ordin s,Rules and Regulati nd all applicable California State Laws: <br /> Tidelcompanyo <br /> Signed x - 7 yI <br /> Print NameY _ DEPARTMENT USE ONLY _ r <br /> r e Y ( :5 60 <br /> SITE MAP IN UNIT TV FILE AD RES ". <br /> WORK PLAN DATED' Area <br /> � r, <br /> a . Date Issued y 2 <br /> Application Accepted By "" .Date Y Final Inspection By <br /> Grout Inspection By Date <br /> Destructlon Inspection By '� <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# .. a <br /> PE CODES FEE INFO AMOUNT REMI TED CHECK R RECD BY DATE PERMrr rA� QUEST# INVOICE <br /> E <br /> ent doe ?_ 9/27/00 <br /> C-57, We WAIVER; C-57 Letter of AUtharizotion to sign permit—Encroachm - !t_ <br />