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NOU-30-2000 15:07 GEOMRTRIX FRESNO 559 264 7431 P.02iO3 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQuIN COUNTY PUBLIC HEALTH SERVICES UNrr TV <br /> 00? <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber,Third Fioor, Stockton, CA., 95202 <br /> (209) 468-W9 <br /> NON-REFUNDABL PERMR£M ES I YEA FROM DATE) I—IBI) <br /> Application s notchy made to San Joaquin County Dior a permit W construct and/or install rhe work described, This appltcabon io made in compliance with San <br /> Joaquin County Development Title,chapter&'115.3 and the Standards o4 San Joaquin County Public Health Services.Environmental HAsssa al SDivis'ron. <br /> WELL Location 8751 E. HighWaV 12 Class Street Bruelle Av.City, Victor Z p 95253 _Parceltl5�-1.3 <br /> PROPERTY OwnerDole Food Compare Address 10900 Wilshire Blvt4llos An elezp 90024Ftone%31524-102? <br /> G-67 Contractor:W IKS�C Add MS L - vnt^vim{-City� P� > <br /> za L;dtso6l5 Phones S <br /> T�Geontatrxx suite 215 it, ntSno uc#&§21Q54xbone# 559-264-253. <br /> Consultant!Suh GdnfraCor r.,ng„ltante, Jac-Address <br /> GIS Coordinates:X Y_ �Township 3NOrth Ransa 7Ea5 Secuent 4 <br /> RK TO EEPERFORMED' <br /> NEW WELL!BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER'OTHERR B DESTRUCTION O R BORE Ill <br /> [ISOIL BORING At B PRESSURE GROUT <br /> 7WvELLk � t - <br /> *Other. GroutSpevficrtions <br /> COMMENTS: <br /> TYPFyq�wEL4 INSTALLATION TYPE CONSTRucrnONSPECIFICATIONS <br /> ZLQE <br /> } ORING ICLLOW STEM DIA.OF BOREHOLE 10 MULTIPLE CASINGS?BYES 39SNO WELL CASING DIA�” <br /> B EXTRACTION D AIR HAMMERIDRIVEN CA51NG 7HICKNES5Sch. 40 TYPE OF CASING: B STEEL WPVC BOTHER: <br /> B VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 55' bgS.. TREMIE TYPE TO BE USED: XKAUGERS B HOS£ <br /> B AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: )'es B No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30'J <br /> B SOIL BORING B RAND AUGER GROUT SPECIFICATIONS: Bentonite cement S1UL'>:V <br /> B OTHER: ❑OTHER APPROX.BORING DEPTH B BOLTED TRAFFIC BOX air B STOVEPIPE <br /> CONDUCTOR CASING PROPOSED? NO (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CAI LTHE UNIT IV INSPECTOR 45 WORKING HOURS IN ADVANCE FOR ALL RE4UIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,Rules 300 Regulations, and all applicable California State Laws. <br /> of D�.�+�/ `c?v`"rrs" �Z' 7itle/CompanY Sei6t o✓' /r7•tAwseH� S/ - t! L�`��rlri <br /> Signed x a, <br /> Ja t r /�'t• /scGc n Date o DU <br /> Print Name pEPARTAAENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> Puy- <br /> VVORK PLAN DATED: {{�� � � <br /> Application AccaPted By a�m Date Issued I Z I D Area <br /> Grout Inspection By 1� ^^^c-,M Date Z b� Final Inspection 6yOate <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AIDr� <br /> pE CODES FEE INFO AMOUNT REMr rrED CHECK s RECD BY DATE PERMIT I SERVICE REQUEST 7i INYDICE <br /> acto( �q.00 oz.Si3� IZlly)� ooa�$3 � <br /> C-57_ WC_-WAIVER____,,, C-87 Letter of AlJthorization to Sign permit—Encroachment ddc__ 9/27/1 <br />