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OG/19/2000 03:30 925-463- '.-,59 ATC PLEASANTON PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> ENVIRONMENTAL <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT A <br /> ENVIRONMENTAL HEALTH DMSION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95242 <br /> (209) 458-3449 <br /> �} NDN-REFU pA8L9 pflRMrt 9-XPIRL5 i YEAR sI P <br /> AppZamon Is hereby made to San Jvaquln cownty for a permit to epnstrurt arWor install the work dita bed. Thi*opplicatlon is made in=mGra+iee with San _ <br /> Joacdn County DevelgpmentTizia.Chapter S-1115.3 and.ihe Snrtdards of San Jw4tiln Catutty Pvlsi�iC_Meea/tip SerVICOS,Ermim mental Health Ctivls(on. <br /> WELL Lnut34rt ✓✓ rvJ/• s4)W4e1 # cross Stme 11erpeY�L��i/� ziD„r-_-;PIA t sad e�f� <br /> PROPERTY Owner Alo F• C �✓�w �AGdress �� rir� s' dCity Y piPhon d� <br /> C.67 Contractors 7��lw r�Add � /z/ Cl ! ,��cO�Z6h-anelt 61Gr/7 f 7Zz.�rTv <br /> �od�o'1 tY ..______Pn dar --fit <br /> Consultant!bub Con&actcr - Address /} <br /> GIS Coardinatrs:N ,Y .Townsnlp� !fir , Range. 49' 1�E 5ertior� 1� <br /> II ORK TO RF,Paa ir0 <br /> (i NE-W WELL I BORING(CPT, ,aEOPROBE.HYD P C 0• E � p DEsrRucrlori(moF�8ORE <br /> aeinw} <br /> SOlL 80Rlf4JG� � 11 OVE <br /> p WELL [I PRESSURE GROUT <br /> Other: Grout SpeCJfkCaGons <br /> COMMENn: <br /> TYPg QF VVIELL I-NSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [I MON171700ING 13 HOLLOW STEM DIA.OF eCREKOLE_MULTIPLE CASINGS?BYES II NO W ELL CASING DI.4 <br /> a EXTRACTION 0 AIR HA.MMERIDRIVEN CASING THICKNGS$_TYPE OF CASING: G STEEL I]FVC I£QTKER: <br /> APOR Q MUD ROTARY DEPTH OF GROUT iREMIE TYPE TO SE U-590: 13 AUGERS Q HOSS <br /> i SPARGE p PUSH POINT GROOT SEAL PUMPED. p Yos R Nc (NOTE:MAXIMUM FREE-FALL DEPTH IS 30'} <br /> 1 SOIL 84►;ING 13 HAND AUGER GROUT SPECIFICATIONS: <br /> D OTHER D 0THER APPROX.BORING DEFY H 17 B04TED TRAFFIC BOX or i]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (VYES,list spearedans here); <br /> -COMMENTS, <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 work will be done in accordance with Sart Joaquin <br /> County Ordinances,Rules a.nq Regulations,and all applicable Calif*mial State Laws. <br /> Signed>S� '" Ti2lafCarttpany �r� — _'�"'� •�7 � <br /> Print Name <br /> DEPART ENT U E ONLY <br /> $rrE MAA IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> App0catien Accepted By Date lssued Area <br /> Grout I"Pecdon ay 17ate� Final Inspection y bat8 <br /> Destruction Inspacdon2ZDate <br /> COMMENTS I CoNorrION6: <br /> COUNTING ONLY: AID; ,.yt <br /> CODES FEE INFO AMOUNTREMITTt_I) CHECKS REC'DSy DATE PERM ITISERVICE RSQUEsT4 INVOICE <br /> C-57 WC WA3:VCR _ C-57 Letter of Authorization to sign perrnit /Encroachment dac `--. 91271W <br />