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62 <br /> 02/08/2001 14:23 20940!'Y1B FILE CgPsymTON - ORIGI <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> RECEMED• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENAL <br /> d7F1$toc ,DIVISION <br /> ktonCPA.SS2 2, <br /> FEB - 9 2001 so4E. W bdr, <br /> (209) 488,W9 <br /> ENVIRONMENT HEALTH NONtirmFUNP -Po EPERIs[TlXp11tE51 E n19madotocampMr aw�Son <br /> pE�T'S c�m�trvaanma inrl a+.,w«x da> e� T;,1��oncad° e1��lu,Dr �- <br /> de to San Joaquln County for a"mu Count Public Health Semces,Envlronm OaSeqaoes <br /> Health <br /> Joaquin County DevWoPmerrt TIUe,Chsptar D-1116,3 and the Standards of Sart � Parcaw <br /> GtY <br /> WELL LQctlon <br /> PROPLI" est; Clry �=�r�Z PAene#Q ZS R}`a opo <br /> C-57 Contrac#ar 1 Addres9 <br /> Comultsnt/Sub Contractor gin <br /> GIs coordinates:x .– <br /> Y Townahlp Ru ge <br /> R [)DESTRUCTION(ohoor�typo ) <br /> WELL I S NG GEOPR05F_HYDROPUNCH,HAND-AUGER,OTftER1 �(�R-L; RE <br /> 100 FW� MC904L BORING 0 1 -3 p PREssuRE GROUT <br /> ij WELL if Grout Specificatio^c <br /> �OthM <br /> COMMENTS- <br /> �N b CONSTRurnaN aPectf►tcATtOt1$ <br /> TYPE OF�J< - &---Tt�—TYPE r' MULTIPLE CASINt3S?f]YES j]NO WELL CASING C)tl� <br /> 0 MONITORING Q�OW STEM DU► OF t30REHOt��c ,� _ <br /> ❑ExT ACTION It AIR HAMMER/DRI�N CASING THICKNESS ►)E1 TYPE QT�M IN YPE TO E USED. $AUGAAS n HOSE <br /> d MUD ROTARY DFPTH OF GROUT SEAL 100 <br /> 0 VAPOR <br /> s'usH POINT GROUT SEAL PUMPED;-gymsNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U AIR SPARGE ' <br /> (j SOIL B0RING D HAND AUGER OROuT SPECIFICATIONS:- P <br /> P <br /> APPROX BORING DEPTH �O r1 p BOLTED TRAFFIC HOX a STOVE PIE <br /> OTHER.� Q QYFIfsi H YE9.Fist spe©Hcatlone hers): <br /> CONDUCTOR CAGING PRq►'46FDT_��- <br /> *COMMENTS: <br /> NOTE: OFFSITE BORIN(35 REQUIRE ACCESS <br /> R CN� �ENCROACHMENT <br /> FOR ALL RI:Gl11RED NSP c ONS. <br /> 6AILL THE UNIT' fV INSPECTVR-VB WORKING HO <br /> I hereby Certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O an sa ulss and Regulation$,and all applicable CalftM1 i<State Laws. <br /> -nU Company <br /> Signed Dow <br /> Print Name ' UEPARTM T USE ONLY <br /> SITE MAP 1N UNIT IV FILE, ADDRESS: O <br /> ClkYJCe�, ck. <br /> WORK PLAN UATF-D: L000 <br /> ( � — <br /> oate Issued <br /> l 3_ Data – <br /> Appiksdw Accepted ey 1 S Final klsDee4io-1 I3Y <br /> Grout Irtepetiion 9y `-moi <br /> oestructlon inspection ey otK. <br /> COMMEN-TS I CONDITV)t` : <br /> E:A:CW7UNT1N1GfjVPEEIN1F=0jA7LM0UkTREMrrM <br /> C?4FCKITREC'D SY DXFF pERWT!1MV$C£REQUEST M 4,� () 255 <br /> permit Encroach►nent dor-_ 9/27/00 <br /> C-57 1NC�WAIVER_—. C-57 Letter of Authorization to signp <br /> P/P 068A `•ZE:Et l0 6 qac `•Z0E0 EtE 5Z6 ` -ouI `6UTjSa1 V 6UTTIT-10 66aJ0 :/(9 luaS <br />