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07/12/2001 07:15 FAX 1&02 <br />11/07/2001 16:09 209466 FIFTH FLOOR PAGE 03 <br />WELL PERMIT APPLICATION FORAM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(tog) "B-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />MOTQ N <br />kPPBratian is hereby made to Sen Jaaquir Gourly tpr •a permit to CQn%hx# andlar ir*W1 em work described. Thhl epplicadon Ie made in eompgancs with San <br />ioagvin County DeveiWmL-nt Title, Chapmr 9-1115.3 and the Standards Of San Joaquin County Pubic Health Sarvicm Environmental Nvetth Division. <br />YIELLLentiprr 13 � .ti � (,v street C �...�keh�tic zp Pa�roa►le s <br />n PESTY o� h1-F10 <br />ss f L ran,,, 3 city. ��v alp 3�PI,or,ek- <br />:-57 Contractor v �o o Addresscity �C4 `�� zip, Siz 17S Phonadf 2�-3 X8 <br />:arrsaFtant sub Contradar_ _ iv; LirL Address -PO2 r235(� Clty�_ue#5,`hGb +one�e �F 38Zb <br />113 Coordinabes: X _.. Y , Trnmship „Bangs 3*ct70A <br />VORK TA 8E FERfORMEQ- <br />NEW WELL f BORMG ( CPT, GEOPROBC, HYDROPLINCH. KAND-AUGER, OTHF-W) DESTRUCTION (Ohoose lyes below) <br />I1 $OIL 50RING # XGVER-SORE <br />11 wie4L # 0 PRESSURE GROUT <br />'Vro► Grout SvsvtYcatlons <br />YCIF. QF WELL <br />INSTALLATiM t•YPE <br />I�AONf70R1NG <br />a HOLLOW STEM <br />FXT ION <br />0 AIR HAMMEWDRIVEN <br />VAPOR <br />p MUD ROTARY <br />AIR SPARGE <br />13 PUSH POINT <br />$OIL GORING <br />(I HAND AUGER <br />QTHER:_`0 <br />OTHEFL_, <br />e - <br />N SPECIFICATIONS <br />PIA. OF SOREHOLe FB ' MULTIPLE CASINGS? Q YES -J NO WELL CASING DIA; Zi/ <br />CASING THICKNESS 0 TYPE OP CAMNO' Q STEEL *Yc 0 OTHER;,` <br />DEPTH OF GROUT SEAL TREM)E TYPE TO BE USED. 0 AUGERS U HOSE <br />GROUT SEAL PUMPED= Yes a No (MOTE: MAXIMUM FREE -FALL DEPTH IS 301 <br />GROUT SPECIFICATIONS. <br />APPROX. i3o"G DEPTH I O Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />Cblvll+ 1cTdiZ CASING PFjOF?QSEDT_ (if YES. Rp spodficatlons heror. <br />NOTE, OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br />CALL THE UNIT IV INSPECTOR 48 WORMNO HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS. <br />hereby "rtify that t have prepared thfs application and that the work will be done In accordance with San Joaquin <br />ounty OQ in>jncss,,�tAles a,"d #"cilAtlolns, and all appflcable California State i-awS. <br />geed K <br />int Na'.--1Fv%'1 H <br />ITE MAP IN UNIT IV FILE, ADDRESS: <br />FORK PLAN DATED: <br />R9 <br />[e7 i I m <br />L..L C <br />1 Z os o <br />�I <br />w <br />)MMOVT'S ! COND <br />4CCOUN'nNOONLY; I AJO4 <br />'E CODES I FEE INFO I ANQLtNT PAM" -MD I CHECK I RRG'P.BY i DATE i I iT1 =l! � <br />Ic <br />-57 WG -WAIVER C-57 Lctter of Author z o sign permit achment doc 9>'27f00 <br />