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08/03/2000 11:16 2094683433 FIFTH FLOOR PAGE 02 <br />WELL PEAIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 I". Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />:pfiCation is hereby made :o San . oacuin County for a permit to construct and/or instal{ the work described_ Tti$ appGoation is mzde in cnrrp6ar.ce with San <br />:acuin County Development Title, Chapter 9-1115.3 ane theeSStar ards of San .,eaqu n Caunr,(Public Health Services, Enw'ronrnental Hearth Diviaion, <br />'ELL Location 1c) u0>e.:-���r G—TC-Ctll�f��Crass�Street , nParcel# ors <br />ROPERTY Owner, t \ (�+•� �-i Atldre fs�s _Say _T('cuc y e)`VflCity r1 r' t zip Q210 _-� 1 �j Q <br />-57 Contractor �f - Address V M �( �r< l city` -6 zipISIS UC# !Z vhone'. Ql ' 77 `14<d <br />ansultant J Sub Contractor ' 'I �_ I l i� � Ue ( C,`t , l Ub E`( ty Lice Cr �"t�Zl Phone# % 3—:x;-,' SS 7 <br />IS Coordinates: X_ Y i cwnship Range Saction <br />ORK TO BE PERFORMED: <br />�tl 'V W ELL / BORING (CPT. GEOPRCBE. HYDROPUNCH, HANG -AUGER, OTHER'; Q DESTRUCTION (choose type below)) <br />(I SOIL GORING # Q OVER -BORE <br />G <br />Q WELL # 0 PRESSURE GROUT <br />)then_ ROUT 5FE'..IPiCATION <br />OMMEN7S: -� <br />(P8 OF WELL INSTALLATION TYPE <br />MONITORING jldCLLOW STEM <br />EXTRA 70N //0 A__jR H.AjMLIER/DRIVE`; <br />VAPOR 0 MUD ROTARY <br />AIR SPARGE p PUSH POINT <br />SOIL BORING Q HAND AUGER <br />OTHER: Q OTHER <br />OMMEN7S <br />CONSTRUCTION SPECIFICATIONS ! / <br />7IA. OF 30REHOLE MULTIPLE CASINGS? Q YES xNO WELL CASING DIAZ— <br />CASING T`fICKNESS (� -YPE OF CASfNG: d ST=_E_ d PVC b O`HE-,: <br />^DEPTH OF GROUT SEALeSr T REMIE TYPE TO SE USED: "J�+UGERS OSc <br />GROUT SEAL PUMPED; �(es f:? No (NOTF- MAXIMUM FREE -FALL DEPTK IS 301) <br />GRGU- SPcC1FiGAT10fJ _ _nn _ <br />APPROX. 80RING DEPTH rX0 r QST [ L'+ ED TRAFFIC BOX or 9 STOVE PIPE <br />CONv^UCTOR CASING PROPQSED^(;f/YES, !is( soecificatlors here): <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />'iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />aunty Ordinances, State Laws, and Runes and Regulations of the San Joaquin County. <br />* CA T E UINIT INS ECTOR 48 WORKING HRS IN ADVANCE FOP, ALL REQUIRED INSPECTIONS <br />gned x___ Titl JCompanyQ <br />;nt Name Dace <br />SITE MAP IN UNIT IV FILE ADDRESS [WORK PLAN DAD UTA\ <br />)plication Accepted By <br />rout Inspection By Date , <br />tstruction Ins Date <br />OMMENTS(CONOrtIONS) SLuc,P kloc k rntA.) ,o✓( ul .lo i <br />ACCOILINTING ONLY: I AID# <br />fnspectfon By Date <br />v. -k <br />S LIS <br />�8 COD@3 I FEE INFO ' AMCUNtT REMITTED CHECK � � REG'i? 8Y l DATE REQ T � I INVOICE <br />Cv%7 FZ9 OD 3� <br />C-57_ WC/WAIVER- C-;,7 Letter of Authorization to sign permit _En aroac meat dec 7/17/00 <br />Eel <br />FA <br />