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Sep-24-02 02 : 34P VIRONEX, INC . 510 568 7679 P . 05 <br /> V 0 1 D 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 to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Cha ter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> p ) r`tV'� S 260 Parcel#or's`b3_ 310— <br /> WELL Location cross Street�PSrw � city S46dcl — Zip -I -- 3K)-06 <br /> PROPERTY Owner < Address City d,1- Zip.q5206 Phone# <br /> C-57 Contractor Vt ao ne X , J rt'- Address r2ilo AVt- City�''-6-'1' Zip4 )l Lic#71'!;a Phone#-'90 <br /> Consultant/Sub Contractor ?C,4W,>1 5 Address 1t)50 �a�I via lA�O M City ZlGh tw4ic# Phone# CS11 13? -3100 <br /> GIs Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> l <br /> Q,NEW WELLORING PT, EOPROB .HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(choose type below) <br /> 0 SZEMRING# S13 l +(- :4� 13-4 p 9LVER-BORE <br /> 1 , (]WELL# e1PRESSURE GROUT � <br /> 'Other: 4- S6-, 1 lfl6/ t GROUT SPECIFICATION Q <br /> -C <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?[]YES IIINO WELL CASING DIA: <br /> o EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL o PVC a OTHER: <br /> [)VAPOR [)MUD ROTARY DEPTH OF GROUT SEAL 86 f TREMIE TYPE TO BE USED: 0 AUGERS CHOSE <br /> []AIR SPARGE *,063H POINT GROUT SEAL PUMPED: []Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) — <br /> eSOIL BORING Q HAND AUGER GROUT SPECIFICATION Cl-Au. — c <br /> []OTHER: []OTHER APPROX.BORING DEPTH k&Z Zo []BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? tQ0 (if YES,list specifications here): <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I 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 THE UNIT IV INSPECTOR 48 WORKING HRS IN ADVANCE OL(LO <br /> FOR ALL REQUIRED INSPECTIONS <br /> Signed xsy�/�� V�t33— Tille/Company Off.>'LO YtA �P IC. <br /> Print Name Date a ti 10 a <br /> SITE MAP IN UNIT IV FILE ADDRESS /WORK PLAN DATED <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued OZ Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: wkjc� <br /> ACCOUNTING ONLY: AID# IV ,Mt �•�� �'l� <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE CII, <br /> S RA <br /> C-57_ WC/WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc` 7/17/00 <br />