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04/11/2001 10:28 2094683433 FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIGES <br />ENVIRONMENTAL HEALTH OrVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 458-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES i YF_AR FROM DATE ISSUED <br />pplication Is hereby made to San Joaquin Countyfor a pemilt to construct and/or Install the Work described. Thls application is made in compliance with San <br />3aquin County Development Tille, Chapter 9-1115.3 and the Standards of Son Joaqufn Cot,nty Public Health Services, Environmental Health Division. <br />AssessQr' <br />/EL.I_Locatlon 400 N. E1 Dorado AvecrossStreetLindsay city Stockton zp95202 Parco� 1s3907009 <br />ROPERTYOwnar Joe Nguyen gddrws400 N. ElDora.do Gty. Stockto91P925202 Phc� 209/941 -8230 <br />-57Contracbbor Vironex Address 2110 Adams Ave. MyS.F. Zip 94516 70594;, one# 510/568-7676 <br />onsultantISub contractor -Orion Eny'1 Address 3450 E. SpringCltyL•B• LietF Phone#562/988-2755 <br />IS Coordinates: X , Y Township T 1 N Range R 6 E Sedlen 20 <br />9 -RK TO SE PERF ED: <br />EW WELL / BORINGS CPT, GEOPRODE, HYDROPUNCH, HAND -AUGER, OTHER) p DESTRUCTION (choose type below) <br />U SOIL BORING # OVER -BORE <br />[I WELL# MW- SSURE GROUT <br />rther. Grout Speeifications• <br />OMMENTS: <br />IPE OF F WELL_ <br />INSTALLATION TYPE <br />MONITORING <br />p HOLLOW STEM <br />EXTRACTION <br />Q AIR HAMMER/DRIVEN <br />VAPOR <br />U MUD ROTARY <br />AIR SPARGEUSH <br />P I <br />SOIL BORING <br />0 HAND AUGER <br />OTHER: <br />n OTHER <br />OWE <br />CQNSTRUC'nON SPEC FICAATIONS • <br />DLA. OF BOREHOLE 6 MULTIPLE CASINGS? U YES (`'yWELL CASING DIA 3 /„ <br />4 <br />CASING THICKNESS 3 r” TYPE OF CASING: []STEEL VC. B OTHER: <br />DEPTH OF GROUT SEAL 41 TREMIE TYPE TO BE U D: p AUGERS a HOSE <br />GROUT SEAL PUMPED: Q Yea p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICA <br />APPROX, BORING t <br />TED TRAFFIC BO or l] STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications 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 />iereb� ycerdt t I hour; prepared S application and that the work will be done in accordance with San Joaquin <br />gun t4nOp-Nkules and Reg lations) and all applicable California State Laws. <br />3ned <br />TIUe/Company, Hydrogeologist/Orion Environmental <br />nt NQme Drummond Date <br />DEPARTMENT USE ONLY <br />TE MAP IN UNIT IV FILE, ADDRESS: <br />ORK PLAN DATED: <br />pllcatlon Accepted ByNLS Date Issued / / l An;a LSP <br />out inspection 8y Date O1Final Inspection( By Dam DI <br />,structlon Inspection By Date <br />WM15NTS'/ CONDITIONS: nt'.A JLA a, S <br />%CCOUNTING ONLY: I AID# <br />'E CODES I FEE INFO I AMOUNT REMITTED I CHECK # I RECD BY I DATE I PERMIT! SERVICE BEQUEST # I INVOICE iI <br />01 t�GR# 00 2-S q I <br />-57 WC -WAIVER C-57 Letter of Authorization to sign permit doc .9/27/00 <br />