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02/e8/2001 14:23 20946ft.e18 <br /> FILE C PAGE 02 <br /> WELL PERMIT APPLICATION FORMO R 4W A <br /> (� ( ' MITIGATION <br /> LIQ IC; ';IF j VE D SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL. HEALTH DIVISION (PHS-EHD) <br /> F F B - 9 2001 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3"9 <br /> ENVI,-n0:'.ENT HEALTH gE�, M-O I DATE RaLLF=D <br /> PEF ,1f TSE; � , NdN �tDA6LE PERy1Ct andt RE5 Yomor TNg flC3Kon is made In compliarm with San <br /> APpucnaon is`Naro t++a�de to San Joy Ktjln County for a Pwmit to mnsfl uCt and/or agkxn ttu work ubfic bad• aA0 <br /> Joaquin County Development Tll}e,Chapter 1-1115.3 and ft Standards of San Joaquin County PubNc Hea1tA S+��s.Envirwunenlat Health Dlvts vn. <br /> Assessors <br /> WELL Loc <br /> aft <br /> n _ Cross S City 1,cis _LParesl# <br /> 0 esE tE t� CFty <br /> PROPERTY - <br /> e-src«It or ; Addr9ea 0 ir� cIrytAf id►fd o�Pt,ene#475� 3-55©0 <br /> Cetaulwnt/Sub Contractor Q�`CIFZle �-Pl,anel� 4�7�f 0��, <br /> GIS Coordinates:X 'Y Tawnshfp Rsnge Soctton <br /> M�PRK TOM DESTRUCTION(ohoo6e typo below) <br /> ' JEW WELL/BORING GEOPROBE.HYOROPUNCH,HAND-AUeER,OTHER-) 0 OVER-BORE <br /> ZSOIL BORING* ( ^3 D PRESSURE GROUT <br /> (] <br /> 'OthM WELL 7i Grout Spedfiwt ons. <br /> COMMENTS- <br /> TYPE OF ML INSTALL.AnQN TYPE rONSTRUCTWN SPECIFICATION$ <br /> 0 MONITORING Q HOLLOW STEM DLA,Of 50REH04-E -Z —MULTIPLE CASINGS?0 YES Q NO WELL CASING OLA:- <br /> 13 EXTRACTION p/UR HAMMERIDRIVEN CASING THICKNESS rLJ A TYPO:OF CASING: Q STEEL Q PVC I]OTHER: <br /> — <br /> (I VAPOR d MUD ROTARY DEPTH OF GROUT SERI. 100 r TREMIE TYPE TO BE USED. &AUOPAS U HC+SE <br /> [)AIR SPARGE :PUSH POINT GROUT SEAL PUMPED:-gY.sspNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Q SOIL 50RING I]HAND AUaPR OROLCT SPECIFICATIONS: <br /> )qOTHER �Q OBER APPROK BORING DEPTH l� _Q BOLTED TRAFFIC SOX or Q STOVE PIPE <br /> CONDUCTOR CASING pROPOSEDI__h2.a_(If YlIS,fat 3pa6Aratlona here): <br /> 'COMMEHT3: <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 /> I hereby Certify that I have prepared this application and that the wont will be done in accordance with San Joaquin <br /> County O an es U10S and Regulations,and all applicable Califomlal State Laws. <br /> Signed TIU4/Campany <br /> r <br /> Pont Namet Otlb <br /> DEPART AAgNT USE ONLY <br /> SITE MAP IN UNIT N Ftl E, ADDRESS; U I rG C �;IYT£y' lt�rli a }QCk�Oyt — <br /> WORK PLAN DATED: ''` ZG co <br /> 13 <br /> A dor Accepted erued4 <br /> Grnui Irmpmcdon By 2l'� �l Date �_I 1 SRmt ktapection By Date <br /> Desruction Inspection By <br /> D*t' <br /> COIAMENT3/CONDrnONS: <br /> ACCOUNTING ONLY: A1D# <br /> Pin CODES FEEINFO AMOUNT REttiNTTED CHECK i Rr-C'O BY nA7E PERMIT r$"V$CE IZEtaUE3T ay tNVOfCE <br /> 3S� 4,� 0 2S�s <br /> C-57_ WGWAIVER— C-57 Letter of Authorization To sign permit—1 ncraachn►�rt doc_ 9/27/00 <br /> — <br /> E/e 86ed .`ZE:EL t0-6-cia-i `ZOCO PLP qZ6 ! 'OUT `6UTISat 'R 6UTTTTJCI 65aJn :Iiia IuaS <br />