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03/2000 11:16 <br />3034593433 <br />FIFTH F!—OCP <br />WELL. cRMIT APPLICATION FC)rcM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />PAGE 9' <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDAELE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br />_:0=ti0n ;$ hereby made to San .:cacuin County for a Permit to wnstrue! andlor :nstait the work describer_ Thi3 appticatian rs made in rnmptiares wi{h San <br />:acuin County [[Development Tltle. Chapter S- 11115.3�a/ne the Standards of San -Cspu n Count,' Public Health SerAces, EnVifonmentat Health oivision. <br />'ELL Location S /f / 6) . �ie(�[r.+� '- Cross Street City i Zip gs��Parcef# ors <br />ROPERTY Owine'rl�� M aldrs Address �1 l 1 W . t 1 +-i_ City _zip S37lehone# 204 k3r5117� <br />-57 ContractorV&-( <br />4 �Jl� Isr `ti m Address 1pi S c."t /10 <br />0077 <br />Cj <br />S�v;css <br />cnsuitant 'Sub Contractor ���h� �N); �n (� es; (p�C �Q{ }� j�{Q� ity �(�( c/ Lj '�,cic�v Phone � 0=7 S--Fh � <br />IS Coordinates: X Y 7ovvrishIp Range -- �- Section -A <br />ORK To BE PERFORMED - <br />N _='rV WELL BORING PT. GEOPRCBE. HYOROPPNCH, HAND -AUGER. OTHER" <br />V4CIL 30RING : (p <br />0 WELL; <br />)then: <br />QMMEN7S: <br />Q DESTRUC)TIQN 1c;hocse arc :C <br />0 OVER -BORE <br />0 PRESSURE GROUT <br />GROUT SPECIFICATION <br />(PE OF WELL INSTALLATION TYPE CONSTRUCTION $FECIFICATIONS <br />MONITORING 0 HOLLOW STEM DIA. OF 30REHOLE L " %1ULTIPL= CASINGS? (I YES ONO WELL CASING OiA: <br />=.x7RAC7ICM 0 AIR HAMMS-RIORNEIN CASING TH!CKNZSS TYPE OF CASING: [I S7 --S_ 0 PVC 0 OTHER: <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL i REMIE TYPE 0 BC USED: U AUGERS [JH05c <br />AIR SPARGE 0 PUSH PC i GROUT SIAL PUMPEC: C Yes a .1,to (NOTE: MAXIM Uhl FREE -FALL DEPTH IS 30'1 <br />-61L SORIR40- 0 HAND AUGER GROUT SP_CI�:;^ATION _ S/ <br />OTHER: j.GT-HcR � XbbC'_, APPROX. 80RING DEPTH o� ol� gl I' 0 gpL; EC r; AFFiC 2CX or Q STOVE PIPE <br />CONCUCTCR CASING PROPCSEb^ (!t VES, !ist Sp c6czdc-s here): <br />OMMENTS: 74 ( O lA fr, <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS dRLfENCROAC ENT ERM[ <br />'Iereby certify that I have prepared this application and that the work will be done in accordance with San <br />ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. <br />1 <br />ti <br />CA L THE U IV INgP TOR 48 WORKING HRS IN ADVANCE FOR ALL <br />REQUIRED INSPECTIONS <br />;,red x �- Title/Companv !�(�C�1dQJ1t"\ <br />int Name L — Ire ^az= 5 U_ a1- <br />SITE MAP IN UNIT IV FILE ADDRESS [WORK PLAN DATED <br />)plication Accepter ey 1A1�F4­44A,-Ips. <br />�,.tlnspecdonSy Lb16ddaw.- Date <br />'tstrUcion inspection ey Oate <br />OMMcNTS ! CONOrrIONS: IA)r•,t .l( <br />ACCOUNTING ONLY: I AIC)V I enr <br />fnsoectfon Sys r Lr r64 ! Date <br />SL4 b' <br />'E CODES <br />FEE INFO AMOUNT REMITTED <br />t CHECK # i REG'D BY DATE <br />/ 5T : INVOICE <br />9q,DQ <br />3s3� I <br />eDoa6 <br />�ER�MIIT <br />0 i' <br />C-57_ WC/WAIVER C-57 Letter of Authorizaticn to sign per4it 17/CO <br />