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Mar -20-02 02:47P VIRC -X, INC. 510 58 7679 P.04 <br />03/''0/2-00'_' 13:04 20946 33 FIFTH FLUUK rwur= _vim <br />tl.D! YJ71 LbU.: U7: JO to �tiooa.vna , i , , `v <br />a <br />WELL PERMIT APPLIGAT�ON FORM SITE <br />;'. MITIGATION <br />�X/�,� vs 2.Og SAN JOAQUIN COUNTY <br />2UNIT IV <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NON �tBFUNDA�LE PERMIT SLP Ication is made in oomplinnce with Son <br />PPll�on is hereby made In amn ,baquin County for a ptrrmit b eene4uct andl0r in3iaU the wort tiv'Ara ea, � H IF, rtrnCht. <br />raquin County De�eloprnwl Titln, Gt�P1er 9-1115.3 and the Standards of San Jnsquin County Erw ronttAental Neelth Daps Assteesors r <br />I c 2! LSV i n r i l r Goes Street Ci <br />FELLloratltxl� t 1022 .w 0 5hrCtnlacr F3i, 'r� <br />I �7 i'Gzn..�Nb � ��1}2/.3 Phorlesx �� - y29 '-S/}'C-% <br />ROPERTyOwner-�lev{� 4h C. _�tddnst i u c City <br />p�� Zl 10 /°ki a''�^� �e CiNs�����[i7 �P�o5927 Pflenes SIO -5b 8 - 7b7(, <br />-57 contractor V t ✓Df��� gg91 <br />onsultantI Sub Contractor <br />[�� 2 C� Addnas5 `-) D C� v Ci^ i C� U ty .oviG-CTf`O LiGfi 13 7't? -2 phOne� q � �-✓y`�=�' <br />Y Township Range` sectlon <br />SIS Coordlna4cs: 7t <br />yppK TO BE PERE_Q ; (j c)asTRL;anoN (choose rn- veto"`') <br />I NEW WELL t BORING ( CPT, [iEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER? 0 OVER -BORE <br />0 SOIL BORING a 1] PRESSURE GROUT <br />other: <br />:OMMENrTS. <br />1 PE OF tt1l�I L <br />INSiA�tAT10N Yarm CCWA ZtIUM SpECWK nDN /Z u <br />iEt- iOfYNG 0OLLAW STEM DIA OF UOREHCL£ " MULTIPLE CASINGS? 1J YE9 Q NO WELL CABIN <br />p, ©2O TYPE OF CASING: I)STEEL ?O C 0 OTHER <br />I ExTRACTION n AIR HAMMEWORIVEN CASING THICKNESS L TREMIE TYPE TO BE UBFD: 0 AUGERS /00SE <br />I VAPOR (I MUD ROTARY DEPTH OF GROUT Sr — '� — <br />u PUSH POINT GROUT SEAL PUMPED: 1) yes ANO (NOT1a: MAXIMUM FREE -FALL DEPTH .) <br />1 AIR SPARGE -p '-f - S I r�Aik" °` <br />I SOIL SOAING HAND AUGER APPROX. <br />GROUT.13CRISPECIFICATIONS; DEP ^`+° �` `' BOLTED TRAFFIC Box. or p mve PIPE <br />I OTHER D OTMER_ — - APPROX. BORING DEPTH <br />SING pROPOSED? (It7R. �ci <br />� sD�fiwtiorw <br />hertj' <br />ICONDUCTOR CI► Ste. <br />61- too 01 <br />GOMMENT3: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br />CALL THE UNIT IV INSPECTOR *0 WORKING HOURS IN ApVANCE FOR ALL REOUIRE.D INSPECTIONS. <br />hereby certify that I have prepared this application and that the work will.be done in accordance with San Joaquin <br />:ounty Ordinances, Rules and Regulations, and all applicable Callfornia State Laws. �r 1r_� <br />Tid¢rGOlnpanY I ' `-GJ I " L <br />5igneC: 1 - _ 40 <br />- 4) QL <br />tt Dak <br />'rintNamc �l�` � •�rr�t�T\1C�tT I ICC AI►11 Y <br />SITE MAP IN UNIT IV FILE, ADDRESS:�i� <br />IHORK PLAN DATED: <br />Pale ISaUad <br />vOcadan Accepted aY, <br />c bale � (` �� Flrral Inspeatlon Ey Oate- <br />:irout Inspection Sy <br />�esYvOlion Insperrtion B DZ}� <br />;ommENT5 f CONDTM MS: <br />ACCOUNTING ONLY: Al DR eer» <br />PE COVES FEE IMFP AMOUMT REWIT" CHECKS RWO BY DATE PETZM1f7 r SERVICE Ria EST TO —INVOICE <br />V3 a - 2 n7- L4� 22 <br />c-57 WCC WAIVER <br />C-57 Letter of Authorization to sign per Mit r. _ achm 1125102 <br />os/oS/v TUE 09:39 IT'X/Rl NO 54041 9003 <br />T <br />