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09/10/2000 WED 17:48 FAX 916 777 4101 V W DRILLING INC <br />09/20/2000 09:15 2094683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />Z 002 <br />PAGE 02 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a p6Yniit to ed 15VUCt End/Or install the work deeorlhed_ This application is made in compliance will r Sari <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Jo quin County Public Health Services, Environmental Health Division. <br />�pyg'i C��b%Y Assasuar'9 <br />WELL Location lk�}Ci.Caur� Cross Street_C-rrAtykkm!c City TYo� Z.1p_7037L Parcel# _ <br />PROPERTY OwnerV e�[- 7Addrass City ZIP Phone# <br />C-57 Contractor V:tjALrN4 Address (O O 5T- sir -e -e4 -CI Zip L6q Li.#j O Phone# jj 7�f �I40 <br />�fj-ra10 <br />Consultant I Sub Contrector0StCn� Address -9¢1 Hn&6 {, CI�Lic# Phone#30 � <br />CO <br />GIS Coordinates: X Y Township Range SacGon _ <br />WOR 8E PERFQRMED;_ <br />��• <br />Q NEW WELL I BORING <br />( CPT, GEOPROSE, HYDROPUNCH, HAND -AUGER, OTHER') DESTRUCTION (choose type below) <br />C <br />1 <br />Q 501E BORING f1 <br />W ELL # <br />OVER -BORE <br />GROUT <br />11 <br />�RESSURE <br />,Other: <br />GROUT SFEClFICATION <br />kA <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS I I <br />O <br />MONITORING <br />'HOLLOW STEM <br />DIA. OF BOREHOLEW MULTIPLE CASINGS? Q YES -ANO WELL CASING DIA yw <br />C— <br />[] EXTRACTION <br />Q AIR HAMMER/DRIVEN <br />CASING THICKNESS_ c� TYPE OF CASING; 11 STEEL 7KPVC Q OTHER: <br />0 VAPOR <br />Q MUD ROTARY <br />DEPTH OF GROUT SEAL a %r TREMIE TYPE TO BE USED: Q AUGERS CHOSE <br />n AIR SPARGE <br />0 PUSH POINT <br />GROUT SEAL PUMPED; I,Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />jj SOIL BORING <br />p HAND AUGER <br />GROUT SPECIFICATION - <br />Q OTHER: <br />Q OTHER—. _ . � <br />APPROX. BORING DEPTH3 1 � __;K60LTED TRAFFIO I30X or [] STOVE PIPE <br />�1 <br />CONDUCTOR CASING PROPOSED? A/(,._ (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 UNI)IV INSPECTOR 413 WORKING HRS IN ADVANCE FOR ALL REQI, FED 1j�PECTIONS <br />SI g n e d x T� &'f !/ { �..�? ; Title/Company <br />Print Name <br />SITE MAP IN UNIT IV FILE ADDRESS MORK PLAN DATED <br />gppllr�tion Accepted R vac rsaucu <br />Srout inspection By. L� Date_.O I S (76 Final Inspecilon lay 01, S �D r-- <br />]astmctlon Inspeotion By „ Date <br />'OMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER ERVICE REQlJ INVOICE <br />a c�U Z 0 - - <br />C-57 WC/WAIVER, C-57 Letter ofAuthorizntion to sign permit ncroachment i ___-_ 7/ 0 <br />09/20/2000 4IEV 04;13 [T-X/Rx NO 61201 Z002 <br />