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02/23/2001 10:05 2094683433 FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HDES <br />ENVIRONMENTAL HEALTH DIVISION (P(PHS -EE <br />304 E. Weber, Third 93t�9 on, 02 <br />( j 4fi8 <br />S,- E N AL <br />MITIGATION <br />UNIT IV <br />DN' <br />NON-REFUNDABLE PE IT EXPIRES 1 YEAR FROM DATE 15U D application ie made In compliance with San <br />>ppliration is hereby made to San Joaquin County for a permit 10 construct andlor install the Work descnbed Tt+�s app Assessor's <br />Healt s <br />in County Development Tide, Chapter 9~1115.3 and the Standards of San Joaquin County Public Health Services s O Ps 1 l#a I Z' <br />loaqu ry , Sioc.k on UP� <br />(► i b 3 611v6g(y p Cross Street, M� —City <br />,WELL Location ^ t*� 1 Zip 93 S Phone# <br />I -, go L4 1 ,11 ! ✓c S� k i 9City,W��r <br />�—Q �O Address_ t>�°T' 3�- Y3� <br />PROPERTY Owner pp R �s Zip?YS'71 Lic# 1� Phone <br />tl1\ Address <br />C-57 Contractor , 2 <br />City 20 a} Phonelf <br />S \ Llot? <br />(. A4fdress <br />Consultant I Sub ContractoSeatonr Range <br />GIS Coordinates: X <br />Y Township <br />WORK TO BE PERFORMED=Q DESTRUCTION (choose type below) <br />U OVER -BORE <br />[JEW WELL I BORING (CPT, GEOPR06E. HYDROPUNCH• HAND -AUGER, OTHER") Q PRESSURE GROUT <br />0 SOIL BORING 4 _ <br />,XW ELL F K Grout Specifications: <br />•Other: <br />TYPE` LL <br />------ <br />INSTALLATION TYPE <br />MONITORING <br />HOLLOW STEM <br />0 EXTRACTION <br />Q AIR HAMMERlORIVEN <br />0 VAPOR <br />p MUD ROTARY <br />Q AIR SPARGE <br />Q PUSH POINT <br />Q SOIL BORING <br />Q HAND AUGER <br />0 OTHER:�� OTHER- <br />t\ <br />CONSTR CTION P 1 I AT10NS NO WELL CASING DIA: <br />DIAOF BOREHOLE MULTIPLE CASINGS. X14 �( OTHER:� <br />CASING THICKNESS SLhC.l 40 TYPE OF CASING FEEL /��C p HOSE <br />TREMIE TYPE TO BE USED: � AUGERS <br />DEPTH OF GROUT SEAL �-- <br />No NOTE: MAXIMUM FREE -FALL- DEPTH IS 30') <br />GROUT SEAL PUMPED: ` Yes Q ( Com �roa�+ <br />c.w <br />GROUT SPECIFICATIONS: oOt BOLTED TRAFFIC BOX or p STOVE Pll PE <br />APPROX. BORING DEPTH ��I - <br />Le - <br />(i YES, list specifications here): �'+" �' S <br />CONDUCTOR CASING PROPOSED? �.$. I X u <br />COMMENTS: <br />r� -%Diimr.S REQUIRE ACCESS OR ENCROACHMENT oc PERMITS. ONS. <br />14V1t: vrr'3rr5- .. <br />CALLTHE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVA <br />have prepared this application and that the work fn1'tll be done in State Laws. accordance with San Joaquin <br />I hereby certify that 1 h P P and all applicable Callfo /�County Ordinarl s,rp{-1les an <br />!!gula�ns, zr - 1 ` G� <br />// / TldelCompany / /O /G/ <br />Signed <br />Print <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: - <br />Application Accepted <br />Grout Inspection By_ <br />Destruction Inspectle <br />COMMENTS I CONI <br />X03 41 <br />Date <br />GU /P <br />4 - iD 0 Area " " Z <br />Date Issued Date�� <br />Final Inspection By <br />ACCOUNTING ONLY: AID* <br />PE CODES FEE INFO AMOUNT REMI'TTED CHECK <br />RECD BY DATE <br />6054D (P G> ?•�7- <br />7J� � <br />C-57— WC_ WAIVER_ C-57 Letter of Authorization to sign permit <br />SERVICE RE r' <br />2:7000 <br />9/27/00 <br />FEB 23 '01 10:00 2094683433 PAGE.002 <br />