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11/28/2001 13:82 2099bbf FIFTH FLUOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> OEC 0 3 all ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> EWIRONMEtiT HEASIH (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Joaquin <br /> Is hereby matle to San Joaquin County for a permN to construct and/or install the worK described. This application is made in Compliance with San <br /> ApplicJoaquin Count'Develop�nt Thele,C P g-1 t�3and the Standards of San Joaquin County Public Health Services,Environmental Health Division, <br /> WELL Location d- ALrL e )or,J Cross Street L✓I&II /1/�. CI •;QqC ZIP c1S3� Arcalit <br /> PROPERTY OwnerSP/ZECIC e-L- 5U(�Al2 Address aO5CO ri0.LV n2 City M9aL_y ZiP_CLjMPhona#209 8'i C. -3.zio <br /> C-51rContractor VIRONEX IAq Address 2'1"110 04HS AVE CilySAr.Ie4AQ$O g'ysV4 }0594Ine# Slo S[of3 '7(o-7jo <br /> Consultant/Sub ContractorTPIFl ar) (C-apop dress SNER19k� "P4141>= <br /> `1 � �" city� j&L Phone# _ "� �4S 7474 <br /> GIs Coordinates:X �e 0.ttUC�lLi�nr. Iwk,/k. (�ctvv ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL I BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# <br /> 0 WELL# 0 OVER-BORE <br /> 'Other: 0 PRESSURE GROUT <br /> COMMENTS: Grout SgpeUllneallons: <br /> SOIL &)R0 7-HPOPV <br /> lA7fa r+o.0 'o2v=G JF(1S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> .MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ '1"-�MULTIPLE CASINGS?0 YES A No WELL CASING DW 3)q� <br /> Q EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING: 0 STEEL )NQPVC BOTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SFALEMIE TYPE TO BE USED: 0 AUGERS XHOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 1)SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: NEAT- CEMFJI r <br /> 0 OTHER: WOTHER &jZ> .V APPROX.BORING DEPTH 16 FEC-T p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: Q� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. Q <br /> I herArertifI have prepared this application and that the work will be done in accordance with San Joaquin <br /> CouI nd Regulations, and all applicable California State Laws. <br /> SigneTitle/Company��ST Z12Z1HYQPQ WAPODA70A] <br /> Print NBJ N" Date IN-06- .�31, 2W) <br /> DEPARTMENT USE NLY <br /> SITE MAP IN UNIT N FILE,ADDFESS: <br /> WORK PLAN DATED: /GI GV/Q.{, bar) 2:gp:t� <br /> Application Accepted By A,�. Date Issued /z.�3�a/ Area CLIA-w(2 L� <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS. <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC•D BY DATE PERMIT/SERVICE REQUEST* INVOICE <br /> 3-t ii- $S. /560 14k r sal 00"220 <br /> C-57____ WC_-WAIVER, C-57 Letter of authorization to sign permit_Encroachment doc_ 9/27/00 <br />