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03/24/2000 FRI 14:58 FAX 916 777 4101 V W DRILLING INC 0]002 <br /> 93/24/2000 14:43 2095305' GEOLOGICAL TECH-) PAGE 01/01 <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 952�,l <br /> (209) 488-3449 <br /> NON-R6FU14DAaLE PERMIT h0[P1RE51 YEAR FROM 2=ISS <br /> O a <br /> Apphoefion Is h4te0y IriMde to Sen Joaquin County for a perra t to oonstlwl and/or Install the work dow . This a14 fl merit jd 3 tom 11 * <br /> San Joaquin County Development Title.CFtiapter 9�i115-3 end the StandanU of San Joaquin County Public Heath A ^yam Heald(t' In <br /> WELLLoeawn 2q(119 LOOmis Rel Cross`Sheet l city S"tock_�Dn AP lS' ,. W - <br /> PROPERTY ow.,—IL-y h�14r�o-,r�,'t ma,rc,i Aaaress g l� SJI q`o,lvt Ll City JPr ^,�ip ,ua `'q, �,1' 8 <br /> G•67 Contractor Ri 1 n Addrl�ss O S � cnynR,�}e este zlpgy�ZLldl'1 pt,on� `7D 3-7 q S <br /> Con:ult,ntI SubCarntramr CG _l/6�i� se5s / GGA-Gy� CIty B Liof� <br /> GIS Coordin>ates:X �Yy� / °"i-s Township Range Section <br /> WORK TO BE PERrsORMED <br /> XN@W WEIL f BORING(Cf-T,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) 1]DESTRUCTION(choose type below) <br /> SOIL BORINGS a 0 OVER-BORE <br /> "Other 1ME11>M 0 PRESSURE GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION CONSTRUCTION SPECIFICATIONS <br /> 1+ <br /> MONITORING / HOLLOW STEM DIA.4F BOREHOLE " MULTIPLE CASINGS?U YEy�9 �4 NO WELL CASING DIA: s <br /> LI EXTRACTION 0 AIR HAMMEWDRNEN CASING THICKNESS_Sc_1 `{O_TYPE OF CASING: 0 STEEL VPVC 0 07HER: <br /> D VAPOR U MUD ROTARY DEPTH OF GROUT SEA ' e 97' .T-REMIE TYPE 7'O BE USED; _$AUGERS OHOSE <br /> aA]RSPARGE V PUSH POINT GROUTSEAL PUMPED: 0 Ygs 0 No (Nod's: MAXIMUM FREE-FALL DEPTH LS 301) <br /> SOIL WRING Q p HAND AUGER APPROX.BORING DEPTH~15� R S� BOLTED TRAFFIC BOX or 0 9TOVE PIPE <br /> Q OTHER ti OTHER, CONDUCTOR CASING PROPOSED7_I„(a„_CWYES,list <br /> 6peoifia6tioha hem)- <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby testify that I IMve prepared this apptiration and that the wodc will be done in accordanoe with San Jesquin Courtly Ordinances,956 taws,and Rules <br /> and Regutationa Or the Salt Joaquin County. Homaouvner or licensed ggvnt's signature certifies the following:y ceriffytlnarin theperforimnce of the work <br /> for which f'rtts permit is issued,l;hap eros employpetsona aWOW to WORKERS'CORPENS.4710PI Laws orCalftyri l" ContrirM a hlfl fig or sub- <br /> contraeft Wgn2wre eirdfies the fouowing:"I cerbf/y th9t 1n the P rfonrreMe offt work for whldr this permit iS Issued,I shall ompky pennons sa4Wt to <br /> WORKERS'COMPENSA710N L&wa orCelMbmlb.- <br /> Mw"TM <br /> Signed L Title <br /> SEE SITE MAP IN U IT IV WORK PLAN DAT D: <br /> p DEPARTMENT USE ONLY <br /> ApplicaQiohAt�eptad By — Dats Issued <br /> Are3- Q,��! <br /> Grout Inspection By Date Final Inspppuon By Date <br /> Destruction InepBy autC <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FGE 114FO AMOUNT REMITTED CHECKA' FREUD BY DATE PERMrf I SERVICE REQUEST# INVOICE <br /> 3-"s-o/ Yl — C7 C10 13 htvQ I A RLM <br /> UNIT IV-6/23/99/dgn bkpg/MT "T <br /> Z'd WOM221 Wd9E:£ 666 l—SZ-0 t <br /> 03/24/2000 FRI 14:40 (T%/R% NO 52981 Z 001 <br />