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06/19/2000 03:30 925-463-2559 ATC PLEASANTON , _ . PACE <br /> WELL PERMIT APPLICATION FORM SITE <br /> auj s� ! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV ON <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber,Third Floor, Stockton, CA., 95202 <br /> (209)468-3449 <br /> N N-REFUNDAfl4>r P RM IT EXPIAR FROM DA7l<tssUP4 <br /> Application Is hereby made to San Joaquin county for a permit to construct armu install the wads dascA d. This applit�Uon Is made in rampliance with San <br /> Devlopmfe3nte.CChapWrr 6.1115.3 and.tho Standards of an Jo"uin County�P�ublic,He3llthSery*=,EnvironmenareaHltet <br /> ahh Division. <br /> Joaquin County I � <br /> �412re Iib <br /> WELL Location s Street <br /> Ciry G,, _ 111 4 <br /> �W 1 1V0�U Addressy %/f/"�u p�� hono" <br /> PROPERTY Owner � <br /> C-57 ContractorSGy����.�� dress399sr/e�is C�G � %�/1 <br /> C �c. Address 6 D.� city Phone# 9a�-1g j <br /> Conaultane/sub Contractor <br /> GIS CoardinateL X <br /> Y Township _Range Section <br /> WD F DESTRUCTION(choose type below) <br /> Q NEW WELL!BORING(CP E0PR06E.HYDD11µA�Ip.AUGER,OTHER-) Q p OVER-BORE <br /> SOIL BORING# (Z�� p PRESSURE GROUT <br /> WELI,# <br /> -Other Grout SperJTlr9tlons: <br /> COMMENTS: <br /> Type OFWFIL JUMLCATION TYPE INSTRUCTION syPCIF{CAT10f�$ <br /> (1 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?12 YES Q NO WELL CASING DUl <br /> Q EXTRACTION Q AIR HAMMERIDRIVEt+1 CASING TNIGKNESS <br /> TYPE OF CASING: Q STEEL Q PVC Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SGAL�TREMIE TYPE To BE USED: 13AUGE=RS Q HOSE <br /> Q AIR SPARGE 13 PUSH POINT GROUT SEAL PUMPED: U Yens p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 307 <br /> Q.SOIL BORING II HAND AUGER GROUT SPECIFICA71ONS: <br /> U OTHER� �Q OTHER CONDUCTOR BORING <br /> E PROPOSED' ll BYE'S I sp TRAFFIC <br /> BO hero);X Or IISTOVE PIPE <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 46 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules ar�o RegUlatlons,and all applicable California State Laws. f� <br /> Signed x � Titlelcompany. <br /> �/,-G�Q.e� �s-lvo Date. <br /> Print Name DEPARTMENT USE ON Y <br /> SITE MAP IN UNIT IV PILE,ADD E S: <br /> WORK PLAN DATED' <br /> Date Issued Area <br /> Application Aoaeptad By /�✓ lL/ <br /> Oats Final Inspection By Date <br /> Grout Inspection By <br /> Destruction Insoactlan By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID" <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY DATE PL"RMIT 1 SERVICE REQUEST At INVOICE <br /> ?' SRA �26.�6 2 <br /> C-57� WG/WAIVER_.. G-57 Letter of Authorization to sign permit!Encroachment doc— 9/27/00 <br />