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Jlo .��.+ .av..•. <br /> u P <br /> 05/24/2001 15:20 209488340 FIFTH FLOOR -_ PAGE 03 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E_Weber,Third Floor, Stockton, CA-, 95202 <br /> (209)4683449 <br /> NON-REFUNDABL PERMIT EXPIRES1 ARFROM DATE ISSUED <br /> 4pplicatlon Is hereby made to San Joaquin County fora permit to oonstN[I anWer instalYEl the Wolk dria(Abed. This aPPI10111e41 IS made in compliance»51b Stn <br /> al HeaJoaquin County Development Thie,Chapter 11115.3 and thi Standards of San Joaquin County PubI1C Health Services,Envtronme Asse sore ivision. 017-090-26 <br /> wEULeeallon_18678 N.ZWY 99 Cress sreet HWY99 city_ACAKEO_zlpM22-LParcelr,_&_n —090-28 <br /> PROPERTY OwncrDENNIS ALEXANDERAddress 21900DEVRIESCdy LODI yp95247,none1209-334-9112 <br /> C-67CootractorePrC UM EXPL0$dre5s7365 WIGWAM DR CI§TOCKTQVp 465-8712 <br /> Consultant I SuD ConvaUor <br /> Address Clty L1cY Phdnell <br /> GIS Coordinates:X <br /> y ,Township Range Section <br /> WO K TO BE PERFORMED'_ U DESTRUCTION(choose type below) <br /> FIEW WELL/BORING(CPT <br /> SOIL BORINGyApROPUNCH,FIAND-AUGER,OTHER') R OVER-BORE <br /> U PRESSURE GROUT <br /> WELL I Grout SPeCiFr ll0m: <br /> •Other. <br /> COMMENTS: <br /> TYPP OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS T�� <br /> MONITORING )WOLLOW STEM DIA OF BOREHOLE " MULTIPLE CASINGS?l]YES y�D WELL CASING DIA: <br /> ROTA <br /> TYPE OF CASING: U STEEL XI PVC 11 OTHER: <br /> EXTRACTION U AIR R/DRIVEN CASING THICKNESS 7 rr TREMIE TYPE TO BE USED: U AUGERS U HOSE <br /> U VAPOR U MUD ROTARY DEPTH OF GROUT SEAL <br /> U AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: U Yor 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or U STOVE PIPE <br /> U OTHER: U OTHER APPROX.BORING DEPTH 0 <br /> CONDUCTOR CASING PROPOSED? (If YES,list 3pac4c.dons here): <br /> •COMMENTS: <br /> NOTE: OFFSITE BORIN S REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOU <br /> RS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and egulations,and all applicable California State Laws. <br /> slgneds /� --- c-e`—� TAIelCompany V PRFS CALTFORNTA CONCENTRATE CO. <br /> Date JULY 10 , 2001 <br /> -rint Name AND ALE ER DEPARTMENT USE ONLYi� \y, <br /> � /�/rr ° <br /> SITE MAP IN UNIT IV FILE,ADDRESS: r <br /> NORK PLAN DATED: 0;;t), 7 <br /> Dale Issued Area <br /> kppllution Accepted By �c—" � <br /> Date ENVia-, 'CHE4;r, C�L'V.rY <br /> 'scout Inspection By <br /> Date 1 a Final lnePeetien By 7iq;�-SE l'Irz� <br /> )estructlon Inspection By <br /> Date -`'Lrr Cll�ec, <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTINGONLYr AID$ <br /> pE CODES FEE INFO AMOUNT REM Iio CHECK I RECD BY DATE PERMR/SERVICE REQUEST O INVOICE <br /> 6379 iB 0 vo 26 20 G <br /> ;57, WC=WAIVER_ C-57 Letter of Authari anon to Sign permit,Encroachment doc_ 9/27/00 <br />