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06/19/2000 03:30 <br />925-463-`'559 <br />ATC PLEASANTON <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PWS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />- (209) 468-3449 <br />PAGE 04 <br />SITE <br />MITIGATION <br />UNIT IV <br />ORIGINAL <br />N -R U Pen 1 gym m2m m issue <br />APPIICatlon Is here0y made to San Jvaquln County for a permit to Construct andlor install the work described. Thi$ opplidatlon is made in onmpliance with San <br />JoaQuIn County Development Tnaia,�C�hhaaapter 9-1f115.3 ond.the Srandards of San Joaquin County Publlt Health SeMoms, Environmental MealU7 Division. Q <br />WELL Location ✓✓O? iV. A �1#&Z1% City ��%� Zip ParcatK � <br />/»y�/�/� Gross Stree r7 %� %� /� <br />PROPERTY Owner 4 ��✓r'y1w _Address �D %%r��/ Si` City + � p, ,! ✓ ��iPhon 9 y ,��/ <br />C�7 GontraclDr7 �%�� / . Ad�dn: / / Gi / c4f� <br />consultant/ Sub Contractor f . Address 4weco 14%�f Ity <br />GIS Coordinates: , Y , Towns►tipr,,, _ oC_ Range _, �^ Section <br />VYQRK TO BE PLRROR16MO, <br />0 NEW WELL / BORING ( CPT EOPROBL, HYD R P C�}� D• E ER`) p DESTRUCTION (Choose type below) <br />/fiSOIL BORING # 7 0 OVER -BORE <br />d WELL 1F _ 11 PRESSURE GROUT <br />'Other_ Grout Spealflcations: -- <br />COMMENTS_ <br />TYPE OF WDLL <br />INSTALLATION TYPE <br />p MONITORING <br />u HOLLOW STEM <br />0 EXTRACTION <br />IJ AIR HAMMEP/DRIVEN <br />Q VAPOR <br />n MUD ROTARY <br />Q AIR SPARGE <br />1] PUSH POINT <br />[] SOIL AORING 1] HAND AUGER <br />U OTHER: 0 OTHER <br />CONSTRUCTION SPr=�jPICA_nONS <br />DIA, OF SOREHOLE MULTIPLE CASINGS? U YES ONO WELL CASING DIEL <br />CASING THICKNESS TYPE OF CASING: 0 STEEL IJPVC 0 OTHER: <br />DEPTH OF GROUT SE TREMIE TYPE TO 15e USED: 11 AUCMRS a HOSE <br />GROUT SEAL PUMPED: n yeas Q No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: <br />APPROX. BORING DEPTH (] BOLTED TRAFFIC BOX or Q STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list spedflcations here): <br />'COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR 44 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, es a�nr1 Regulations, and all applicable California State Laws. .,'/%�/��rf/� <br />signed x <br />Print Name <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 55 J S <br />WORK PLAN DATED: <br />Application Accepted By = Date Issued Area <br />Grout Inspection By —_ _ _ Date Fina{ Inspection y Date <br />Destruction Inspection 5y Date <br />COMMENTS ! COND171710NG! <br />ACCOUN-nNGONLY; I AID# <br />PE CODES FPE INFQ I AMouwr RsmmrED CHECK 0 RECD BY DATE PERMIT / SERVICG RIaQUEST u I INVQICE <br />C-57- WC WAIVED C-57 Letter of Authorizn,ion to sign permit! 9/27/00 <br />