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03/24/2000 FRI 14:58 FAX 916 777 4101 V W DRILLING INC Z002 <br /> w03/24/2000 14:43 2095305E GEOLOGICAL TECHN� PAGE 01/01 <br /> - f <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 952.02 <br /> (209) 488-34.49 N;, , y <br /> X, 419 •.� <br /> NON NDA PERMfT RE6 1 YEAR FROM DATE C';. arm <br /> Applieation la lteMby triage to San Joaquin County for a permit to wnshud and/or Inatall the work dodo . ThisLapp30cat,W-i„t�gs milled cornFGenad wrth <br /> San JOaquln County Development TkIek.chapter 9--1115.3 and tho Standanda of San Joaquh+county PublIcc Health BarY(86a,f#ey�r Health 1301*g,.y� <br /> WELL Location 2q 9 L oomi S R k Cross Street City J fo c)/_ 'O 1 <br /> -;rip '7 <br /> PROPEfrIY Ownerlr;► r m4r�grc� r,:,Aadress �a81�o S�°11o�,vlL 1'dCItY Jfr�^,Tip`�5�52�Fi�Sr ` oq• '1,1ZI— Q <br /> C•67 C=/SubQonlraM�._ <br /> or Ri 1'n Addraws�'O Q O-, S 1 City 7fp�5lZLlc y1�b fpm n��'1D'''�”37`�asrs <br /> CTxi4 �6&6/4�d.� drags `// f2cwU LU City."2� Lioix �Fione# 3�^6Ya_y <br /> GIS Coordiruttee:X 6G O t Toumshlp Renga Section <br /> WORK TO BE PGRaORMED <br /> XNEWWEN LL/BORINO(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER') p DESTRUCTION(cho&"type below) <br /> SOIL BORING# a IZ OVER-BORE <br /> -other: tAIELL* 0 PRESSURE GROUT <br /> COMMENTS_ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !r <br /> )'MONtTORING ti..' *HOLLOW STEM DIA.OF SOREHOL " MULTIPLE CASINGS?a YES %NO WELL,CASING OW <br /> 0 EXTRACTION Q AIR HAMIUERlDRIVEN CASING THICKNESS Sc_� `}O TYPE OF CASING: 0 MEL PCPVC 0 OTHER: <br /> 11 VAPOR [I MUD ROTARY DEPTH OF GROUT SEA r TREMIE TYPE TO BE USED; '$AUGERS (1HOSE <br /> Q AIR SPARGE [1 PUSH POINT GROUT SEAL PUMPED: a Yes 0 No (1140 re, MAXIMUM[FREE-FALL DEPTH IS 30') <br /> SO{� pWfV <br /> 90RIN0 O FD AUGEPR <br /> R ApOX.BORING DEPTH~I5 ! R S <br /> BOLTED TRAFFIC BOX or p STOVE PIPE <br /> Q OTHER ❑OTHER CONDUCTOR CASING PROPOSED?�Q -_CWYES,iist 6pe.ifiogtions hare)• <br /> COMMENTS' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that 1 tRve prepared this application and that the work will be done In accodanue wdh Son Joaquin County Ordinancw*,Swo Laws,end Rules <br /> and Regulativna or trio San Joaquin County. Homeoum w or licenced 4g4nt's signature certifies the loitowing: `7 cerSfythatfn the performance oftho work <br /> for which tills permit is isstmd,I jF1re/1004 ermploypersona goofed to WORKERS'C0wPENSA7j0N laws of C4w1lfomta,1 Contractors hlrltig or sub- <br /> contractblg sigf)2tWra c6rtlrie6 the f0110VVing:1 certify that In the perfonneWa of Ne work for which bN3 pwmR 1s lsgwd,1 shall amplay par==subject to <br /> WORKERS'COMPENSATION Lawn of cemlbm/a." <br /> zNil 0 WON _ <br /> Signed Title beta CPO <br /> SEE SITE MAP IN U IT IV WORK PLAN DAT D: 3-9 - COo <br /> n DEPARTMENT USE ONLY <br /> ApplicationAtzepted By Date Issued 3 _-;-2' —U Area, _ <br /> Grout Inspection ey Date Fjnal Inopoctlon By Date <br /> DaWucdion Inewltion By abtC <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REW117TED CHECK 9 MC'D BY DATE PMfT 1 SE3ZVICE REQUEST# INVOICE <br /> UNIT TY-6/23/99 1.19.bkpg/MT <br /> 03/24/2000 FRI 14:40 ATX/RX NO 52983 Z001 <br />