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OP./20/2000 WED 17:48 FAX 916 777 4101 V W DRILLING INC 0 002 <br /> r 09/20/2000 09:15 2094683 FIFTH FLOOR • PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD UNIT IV <br /> 304 E, Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit m construct and/or install the work deeorlhad. This application is made in compliance Ad i Suri <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards of S nn JJcaqujn County Public Health Services,Environmental Health Division. <br /> WELL Looation 1 (P pia3 ` arcei#or's <br /> (♦11MK iL L�Caur� cross so-eett CqTGK city TY'a ,_zlp��Js parcel# <br /> PROPERTY Owner C k41-v 4 7�Addrass City71p Phone# <br /> 0-57 Contractor V-(:,�j),-tt1Yi I 11 Ls j Address 10 O -9'T"S}rKr.S- CIpd;S IY{M-Zp fVy Licifj2 0 phone#51G <br /> Consultant/Sub Contrsctor tL L Po�a I' Address SArfYalO L <br /> r�-1 � � � �1�f�1N.�.fi_Glyl/¢rey,LicirPhone#S'O R� <br /> GIS Coordinates:X Y ,Township Range O _ SecOon _ <br /> WORK TO 6E PERFORMED4 <br /> C NEW WELL/BORING i CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> n SOIL BORING N C OVER-BORE <br /> D WELL# RESSURE GROUT <br /> 'Other; GROUT SPECIFICATION <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> KMONITORING HOLLOW STGM DIA.OF BOREHOLE j r• _MULTIPLE CASINGS?0 YES -,NO WELL CASING DIA: 2-It <br /> 11 EXTRACTION a AIRHAMMER/DRIVEN CASING THICKNESS 5JA 9r) TYPE OF CASING: ElSTEEL 7KFVC 0OTHER: <br /> a VAPOR C MUD ROTARY DEPTH OF GROUT SEAL_ a" TREMIE TYPE TO BE USED: n AUGERS CHOSE <br /> n AIR SPARGE D PUSH POINT GROUT SEAL PUMPEC: J1,Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 11 SOIL BORING 0 HAND AUGER GROUT SPECIFICATION-am+Agi _ <br /> n OTHER:_[]OTHER_ _- APPROX.BORING DEPTH_%.1 1 --,ASOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED?lV J. (if YES,list specifications here): _ <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <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,State Laws,and Rules and Regulations of the San Joaquin County. <br /> *CALL THH5 UNVf�IV INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REOVj RED 1pF PECTIONS <br /> Signed x I /11/" <br /> 1 /,I�.�/ �' :�- TIBe/CompanY � <br /> Print NsmN 'i l I� by-10,11, Cate <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED FILE Ct 1p y <br /> I=_PARTMENT USF ONLY <br /> 9pplication Accepted 11 _ Date Issued 2 le, IArea <br /> Grout Inspection By Date 01 IS i yo Final Inspection 5y O° S <br /> �eatnl CdOn InspeCaon By Date <br /> :OMMENTS/CONDRIONS: <br /> ACCOUNTING ONLY: AIL <br /> PECODES FEEINFO AMOUNTREMITTED CHECK# RECTO BY DATE PERMIT/SERVICE REQUEST INVOICE <br /> 2 90Z 6orC)o I X0`6 til bKo1 OC2 AH q . <br /> C-57_ WC/WAIVER-- C-57 Letter of Authorization to sign pe mit—Encroachment doc__ 7/17/CO <br /> 09/20/2000 $TED 09;13 (TX/RX NO 51201 X£]002 <br />