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WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON•REFUNDAELE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby Made to San Joaquin County for a permit to construct andfor install the work desdibed. This apphrallon is made in compliance with San <br /> .loaquin County Development Title,Chepler 9.1 115.3 end the Standards of San Joaquin County Public Health Services.Fnvironmp tnIS�H Health Division <br /> WELL Locatlen_ <br /> Lodi Sewer TreatmentrnngStroet Hwy 5 CiryLodi <br /> FRCIPERTY Ownery.. <br /> _ <br /> Cit Of Lodi Addrocs City <br /> _ _ —-- ---- - - ------- <br /> Syivie C. Jensen �� z„9569LL __phoneti916-373-1118 <br /> C-57 Contfactor#5 5 219 8 -- -----,Addres5P—Q, _BOX_16 6-4_—�tm Sac.-- ;c--. <br /> Saracino & Kirby, nc 555 CapitolMa,, j sac_I ira Phonea916_329-9199 <br /> Consultant/Sub Contras r nd r►5s ---,_.,._ <br /> DIS Coordinates:X <br /> y .Township_ Rnngn- -- __ __—_Section-- <br /> WORKTOBEPERFORMED_ IIP RASE -SRF ATTACHED” <br /> �DESTRUCTION(choose"e below) <br /> )KNEW WFLL f BORING(CPT,GEOPROBE.I IYDROPUNCl1.HAND-AUGFR.OTHER`) []OVERBORE <br /> U SOIL BORING#_ _ _— ---- n PRESSURE GROUT <br /> Grout Spedfirations' __._------ - - <br /> COMMENTS-. <br /> TYPE OF WELL, INSTALLATION-TYFE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING )(HOLLOW STEM DIA OF B8OREHOLE inch-MULTir�e CASINGS? YES *10 WFI 1 CASING DIA: 2_1riC11 <br /> 0 EXTRACTION 0 AIR NAMMER/DRIVF.N CASING THICKNESS�CH-__4 0 TYPE Or CASING: 0 STEEL *PVC ❑OTHER­ <br /> DEPTH TYPE TO RF USED AUGERS Q HOST <br /> U VAPOR p MUD ROT DEPTH OF GROUT SEnIT?T1: _— <br /> p AIR SPARGE U PUSH POINT GROUT SEAL PUMPED:lLyor'CemenNo t (NOTE:BentMAXIMUM FREE- ALL DEPTH IS 30') <br /> ite <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS. Fe��—NBOI_TED TRAFFIC BOX er STOVE PIPE <br /> iJ OTHER 0 OYHFR__--______ APPROX:BORING DEPTH <br /> CONDUCTOR CASING PROPOSED-?N0 (11 YES,list specirications here): <br /> 'CUMMFNTS: -_ ----- <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 is application and that the work will be done in accordance with San Joaquin <br /> County 0 d��es Tiles and Relations,and all applicable California State Laws. <br /> !� 7 r�nelCempan�_General Manager/Western er/W_estern Strata <br /> Signed)( ' — ff Exploration, Inc. <br /> Print Nam Gordon`'D. J s �n, Jr. _I)at�__ 1_ l <br /> "--- DEPARTMENT USE ONLY <br /> LIZ <br /> SIT E*CiNP IN UNIT IV FILE,ADDRESS: -- <br /> WORK PLAN DATED: _- -" <br /> Date Issued _ __ __Area O CVIQ � <br /> Application Accepted By _ —. — Date <br /> Grout Inspection By �� _Date �VrFin;it Inspection By --- <br /> Destruction Inspection By Date <br /> COMMENT SICONDITIONS: ? C L" <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK A RECD BY DnTE PERMIT f SERVICE REQUEST A INVOICE <br /> 9�27�00 <br /> C-57^ WC--WAIVER— C-57 Letter of Aunthorization to sirmit_—Encroachment dot— <br />