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I <br /> 0425/2002 08 20 GEOLOOP DRILLING a 19165654356 NO.079 907 <br /> 6, v)j WELL PERMIT APPLICATION FORM sn-E <br />' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION�' ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 466-3449 <br /> ntll_F PF-AM[[EXPIEIR t VeAA FgDMDATF ISsuED <br /> -cation is hereby fnade to San Joaquin County for a parmli Io oonstruct and/or invall t1io work desor'ined This application in made in compliance cath San <br /> Muir)County Dav �ppmanl Title Caper 9,�i is 3 and me Siandwds of San.Ioaquln County Public Health Sarmces Enviiovimentef Health Division <br /> rr•tt'�1T� L��.s� •tiv 1 Ast;eBsor's <br /> ELL Location 3455b Arnrrmpe. L.a Cro6s S req ,L GIIV�..liiSrJu"Wji Pare <br /> PE TY owner ` V b <br /> atcctor T�rrf.P'c.jm ( � A�ddress G e <br /> dre&sC, a=UZcP019_�M5Z_(0P an�onee9 <br /> � <br /> -- <br /> 01 <br /> uitantl Sub Contraeter rOcYPA�ii�i.�Address 13ZJa (V icA _ <br /> —Phones 13 7v <br /> Y ,Township-----_- Range _ -_Section <br /> aFORMEfl- <br /> (v LL 80RIh1a1CPs'Lt3>=OPfio9E,HYDROPUNCH,HAND-AUGER 0-rKER-) d PESTRUCTIQN(choose type below) <br /> [�SOIL ESOPIING 9 --- - Q OVER-BORE <br /> )(WELL# .MVO- I mV+1f:-1PRESSURE=GROUT <br /> tt�er: Growl Spaclflcorions <br /> MEMS l+ �7 Z- Z3 <br /> IE OF WELL lNS:f1SLLATt0N TYPE_ CONSTRUCTION SPECIEICATION9 <br /> MONITORING `' IOLLOW STEM DIA OF BpREf IOLE �MUL-ni LE CASINGS'[]YES'�i0 WELL CASING DIA. It <br /> PkCt1iON [l AIR I-rAMMERIDFIJVEN CASING THICKNESS%tk k 1�/�7YPE OF CASING U STEEL WVC U OTHER. <br /> [l MUO ROTARY DEPTH OF GROUT SEAL-'V�j I- ... ITREMIE TYPE TO BE USED {l AUGERS RHOSE <br /> AIFI SPARGE 17 PUSH Pal hrr GFIOLrr SEAL PUMPED []Yes Pa (NOTE MAXIMUM FREE-FALL DEPTH IS 3E]') <br /> IL BORING []HAND AUGER GROUT SPECIFICATIONS <br /> OTHER APPROX 90RING DEPTH_.+ ZS VBOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? PV0 (rf YES list spcaficalions here) <br /> ENTS <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 /> reby certify that I have prepared this application and that the work will be done In accordance with Son Joaquin <br /> ounry Ordin yes, Rules a 0 Regulatl ns, and all applicable California State Laws <br /> x TitlolCompany. e <br /> I <br /> int NBme L{ <br /> DEPARTMENT USE ONLY <br /> ,, <br /> MAP IN UNIT IV FILE ADDRESS: &y575 <br /> IRK PLAN DATED:___ /2, _ <br /> catron Accepleq By,_ _, Data issued <br /> aui)nspaclian ey _ Dale Flnsi Inspecuon By __� _ _—Date <br /> action Inspection By pate <br /> CONDMON <br /> ouNTING ONLY, AID# <br /> car•u <br /> ODES FEEINFO AMOtINTREMI[TTEp CHECK# RECIDBY VATF PF_RM1Tl9F_RVlCP_A1501lESTa INVOICE <br /> s Rit <br /> WC -WAIVER C-57 Letter of Authorization to sign permrf ✓. I ncroochlnent doc 9127/00 <br />