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Sent By: Toxichem; 510 595 1288; Apr-25-02 8:0BAM; Page 3 <br /> 011zn1,ztsn1 Ob-54 20946$3433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E_ Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NOWRIFUNDABLE PRRryILT EXPIRES 1 YEAR FROM DATE IS-11JED <br /> Application is horeoy made to San Joaquin County for a permit to construe[anWor install the work described. This application is made In compliance with San <br /> Joaquin County 0evebpment Title,Chapter 9-1115.3 and.the Standards of San Joaquin County Public Health Services.Environmentai Health Division. <br /> ��1, �y3 j Cross Street - Assessors <br /> WELL I_acation <br /> �; _ Ciry cY � 21p . G3 <br /> PROPERTY OwnerLIr-t- l�:>T=- T _Addro6s7jL'( 4),AL4City ".[,yLC Z-(6 <br /> C-57 Contractor I4:i:h Addressgri- �t .0'G err. Ci a.r ip`�r1 Lid fly Phonerl`f 7.5` ✓� C C <br /> ConsultantlSub CCity �r LiGK Rhone#` U � -� s4LJ <br /> GIs Coordln3teS:X Y Township Rangy _9actun __.. <br /> WORK TO BE PERFORMED: <br /> NEW WELL!BORING(CPT,GEOPROUE,HYDROPUNCH,HAND-AUGER,OTHER') Q DESTRUCTION(choose type 4alow) <br /> U SOIL BORING# (I OVER-BORE <br /> WELLtJL 0 PRESSURE GROUT <br /> 'Other: Grout Specifieatlons; <br /> GOMMEN7S:o�fi�•rin� �`tv+t-r � ? �c�r-��y1t � j�'lu, -l7 ;VC-[ �f�.�CLA j <br /> TYPE OF WELL INST LATI CONSTRUCTION SPECIFICATIONS <br /> ,, ONITORING ?FT40LLOW STEM DIA OF BOREHOLE " MULTIPLE CASINGS?Q YES'V_NO WELL CASING DIA_ .-r <br /> 0 EX TRACTION U AIR HAMMERJORIVEN CASING THICKNESS TYPE OF CASING: [I STEEL C Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE 70 BE SED' 'Q AUGERS >OSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: Q Yes IQo (NOTE: MAXIMUM F(REE-FALL QEPTH IS 30') <br /> Q SOIL BORING Q HAS�NQ AUGER GROUT SPCCIMCATIONS;� -u-c" !~�o �7C;t- --G CN�-T<- <br /> U OTHER:_11 OTHER APPROXI BORING DEPTH _:*d[OLTED TRAFPIC 60X or p STOVE PIPE <br /> "t" CONDUCTOR CASING PRQPQSE07 .r`+L� it YES,list specificationS here)' <br /> 'COMML NTS;teakK J� <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMI=NT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS 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 Or iqa aes, Rules and Regulations,and all applicable California State Laws. r <br /> Signed / r - "1f - J l i- TitiwCompany c9` _ Y' <br /> Print N�4 . ' pats `Ti L- �G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILF,ADDRESS: <br /> WORK PLAN DATED' !/ <br /> Application Accepted By-b Le�-It � _Date Issued 102 <br /> Grout Inspaction By 4aIq Final Inspection By Date <br /> Destruction INspLtillorr 8 ��- Date <br /> COMMENTS 1 CONDMONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INTO AMOUNT RFMITTEII CHrrCK it REC'O BY DATE PFRM17/5ER+tG!R1EgUE5T# INYQIC> <br /> �� ac 1355 .J(� �3dDL. UO�Co2-7 <br /> C-57_ WC=WAIVER C-57 Letter of Authorization to sign permit_,— Encroachment doc_ 9/27/00 <br />