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MAY-20-2002 03: 19P FROM: T0:19163B34OB4 P:4/5 <br /> WELL PERMIT APPLICATION FORM TE <br /> N1 TIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTALTn iDIVISION ) <br /> 304 E.Wr, d Floor, CA 95202 <br /> (209) 468-3449 <br /> ON FUND PE M XPIR OM TE 13 ED <br /> for a rntll to cpnslruct rand/or Install the w0�desCrlOed. Thl7 BPPlipdon's made in compGenra w17+San <br /> tpplication Is herb*made to San Joaquin County o pe Public Health Services,En�ronmennl Hahltessor' O,vio en. <br /> ASSessofs <br /> baqun Ceunly Development Tide,Chapter 9-t I 1 S 3 and the Standertl!of San Joaquin county 7 rp 45-2 <br /> �parceig 0 17 -Oq-o�S <br /> N, a, I,�, 9q Croon Stn-el�'b"p6hpd� City c <br /> NELL Location I 1 L. <br /> y6L honrf ±/A <br /> >ROPERTY Ownar N'r_HA`7` 0 "9I a s Address <br /> ,4qo I.Aaoaa Q. oty�q�E�1RL:- Zlp --� <br /> Ip Phanett_ <br /> ` l � �Gry- - _ <br /> C-61 Contnctor `C)Od Nee) Yi res9� _ -- 1 lion^r_Phones-__-.— <br /> Address <br /> hones _ 3 <br /> Addrell (p2k��a wy�C1tY� `VJ <br /> Con6ultant/3uD Contrndor� ( R'nee 7E Section J/ <br /> Township <br /> G13 Coordrnatec X _-_._----•Y,� �-- <br /> WORKTO ERF M Q: p DESTRUCTION(d�0Ese gree be1oW) <br /> �OVER-BORE <br /> ANEW WELL/80RING(CPT, ROSE,HYDROPUN N• t D AUGER,OTHER-) PRESSURE GROUT <br /> RCSOIL BORING p D- <br /> U WELL 1t Groul Spec,tlcation s <br /> 'Other: <br /> COMMENTS' <br /> CONST UCTIO P CIF TI NS WELL CASING DIA. <br /> at OF WE�1 T—AL�ATIQ�P� MULTIPLE CASINGS,)fl Yss 0 NO <br /> DIA.OF BOREHOLE--- <br /> a MONITORING 11 HOLLOW STEM Type OF CASING p 9TCEL Q PVC OTKER._ HOSE, <br /> AIR MAMMEp4DRIVEN CASING THICKNESS_— TREMIE TYPE TO SE USEO U AUGERS 0 <br /> EXTRACTION D 05PTH OF GROUT SEAL_____�- <br /> 0 VAPOR Q MUD ROTARY Yea No NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q AIR SPARGE, p PUSr�POINT GROUT SF.�-PUMPED: � O <br /> GROUT SPECIFICATIONS STOVE PIPE <br /> Q SOIL PORING Q RANO AUGER APPROX.BORING DEPTH___-------- BOLTED TRAFFIC 80X or Q <br /> (If YES-112t <br /> apedbcaGe"!he(e): <br /> a OTHER'_ � 0 OTHER, <br /> CONDUCTOR CASING pROPOSED7��_ <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQE ACCN A vOANCEIFOR ALL R CfU RED INR ECTI <br /> UIRONS. <br /> CALL TM <br /> UNIT IV I CTOR a8 WORKING HOURS <br /> f t at 1 have re ared thlt application and cablthe <br /> C work <br /> kwill <br /> Il$tate Laws done in accordance with San Joaquin <br /> I here l a d Regulations, and all app <br /> CO ty Ordl /ices, <br /> 1. TillefCOmPanY�na aGet 6;: <br /> Sig Data $-?1J-OZ "-1 <br /> Pfint )q'fi DEPARTMENT US>^ ONLY <br /> SRTF MAP IN UNIT IV FILE,ADDRCSS- <br /> WORK PLAN GATED: G L Area <br /> ( ( I d Date :Sue <br /> l`c ✓�`- • Date <br /> Application Accepted By r Date Final inspection By <br /> Grout Inspection By DaI� <br /> oawaion Ins eaten ey <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AV C / Y DATE PERMIT/sERvICE REQUEST A INVOICE <br /> � , <br /> PECO FEe INFO MOUNT REMITTED CHECK CK J <br /> hment 9/27/00 <br /> etiv.r of Auth iz/ io o ,gnp�rmit,._.EncCoa� doc`— <br /> G <br />