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06/19/2000 03:30 925-463-)559 ATC PLEASANTON PAGE 02 <br />nbr ,1. u/ 1bb1 l0: 13 20941 33 FyFTH Fim.00R2 <br />PAGE 0� <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM SITE <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES TION <br />UNIT I <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT V <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 466.3449 .2-& <br />NON UFUtDMLE PERMIT EXPOS'} YEAR MM DAMS591! <br />Application 19 hereby made to San Joapuln County for a pormlt to construct and/or Install the work desctibod. This application is made in complis"Ce with San <br />Jonqu(n County Devellcrp(/ ee,Ennat 7 itle,/C�bepterr 9--11111155.3 Anyd,the Standarcss of San Joo*4uuinn County PuOlic Health Servicos, Environmentsl Health Division. <br />�✓ V ✓ L��/�/!�/ !J/. CGS Ci ASS29g0{s//o <br />wELL Location Crus: Stree ry.�%% ZP Parcrifil Q/�/ <br />PROPERTY Owner; �/ almegge Addd/25sJ��y�%�� C1ty ��J Q�Ptlone# ✓� +gyp �y��'t�7" <br />C.57Contractor?/�a' fi �����`",, ddress�`1� �i/'./�n�/'•n City, - '�ic�f ��t�honeM/Of�7' �"✓✓7'� <br />Gunsuttarrt /Sub Contractor 7T 1�.� Address 6�p1�7,6��%�,iis.. Citylo#_ /'%T PhaRe417� <br />GIS Coordinates= X Y , Township ae41 Range 40-- ef-7 Stetson �a <br />WORK TO Br;_PFRFO!5MLD: <br />0 NEW WELL / SORINO (OP GEOPROBB, HYD�j,OP}�NCM, ; A UGER OE UCTION (choose type below) <br />OIL BORING # J%��'^ �� /�r`6. �/� ��/� $%�C �/"i -01� 0 PRE SURE GROUT <br />p wELG <br />'Other- Grout Specifications' <br />COMMENTS: <br />TY OF W E L <br />jNSTALL6n0N <br />0 MONITORING <br />Q HOLLOW STEM <br />11 EXTRACTION <br />p A1R HAMMBRIDRIVI=N <br />Q VAPOR <br />fJ MUD ROTARY <br />p AIR SPARGE <br />p PUSH POINT <br />D,SOIL BORING <br />Ij HAND AUQER <br />17 OTHER- <br />0 OTHER - <br />*COMMENTS: <br />CCON$TRUCTION SPZ0IFIGATI.0N <br />01A. OF BOREHOLE MULTIPLE CASINGS? DYES ONO WELL CASING DIA <br />CA$ING THICKNESS TYPE OF CASING: O STEEL I] PVC p OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 13AUGERS a HOSE <br />GROUT SEAL DUMPED: p Yas p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH Q BOLTED TRAFFIC BOX or a STOVI! PIPE <br />CONOUCTOR CASING PROPOSED? ( if YES, list gperlfrations here); <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances. Rules and Regulations, and all applicable California State Laws. <br />Si9nod <br />Print M <br />�/' 67/cA%le <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED: <br />S'u)D,e,'A- <br />Sj"'17V 564x, <br />Application Accepted Sy G Date Issued l / __ Ar Z_�2 <br />Grout Inspection By Date _ final Inspaction By <br />Destrualon Inspection By Date <br />COMMENTS r CONDMION6: <br />u �/rrrrll u-w�s•/iprYn m r <br />ACCOUNTING ONLY: <br />AID# <br />FACIt— <br />FIECOIDES <br />FEE INFO AMOUNT REMITTED <br />CHECK 0 REG'D BY <br />I DATE PLRMIT / 9ERVIC6 OST 0 INVOICE <br />301 <br />2--q0<;� <br />C-57 �- WC✓WAIVER G-57 Letter of Authorization to sign permit; n c,,,^ 9127/00 <br />