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06/28/2001 15: 40 209-579-"?5 MODESTO ATC PAGE 02 <br /> 01;/20/20E1 07:27 2994683a'�3 FIFTH FLUll IGINAPAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS•EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 458-3448 <br /> N N,QFF LEP MITEXPIR"1 YLAK R <br /> Appilattor It:nenby rnul.to San Joaiquin County for a pwmit to conatryvl anG.'or initgli tnf worK deacribed, Thie tlnpllc8ti0n is mads In xmptlanoe w t1t Srn <br /> Joaquin county CevefoMent Titic Chanter 9.11 IS.$and lite Standall or Sen ill Caurty p.jI i�c�Hlaoal:h StrvIC'SS.EnnvironTenta;health l <br /> YYELI l.eratbn �� >�JH�� �It►Ni Cross 9trf®t 'fir-��a -Clty,����' ---�''P.-t.:�:-PsraM� <br /> PROP Ill Owns[ 'A jj ' _A�..dress PX41,x CRY Sov, d;.y4 ztn yti hon.# (blr.l <br /> C-57Contra=r Addroas 34t S�nl.��S 1�1ti4. CityVatI�Y c 4yt?tLiel��d7'D65pnenfA ' i —3S 3 <br /> Cov3uitant�Sub Contractor JETL t CSOwe AdCrass ILIA' Law lw Clty/��dLil�Lida PhChsN "LZZ1 <br /> t8)S Covrdlnatea:�. Y Townthlp^T; Range _ SfeMM <br /> P <br /> EW WILL/@,0'l(CP,3Ill 00ROBE.HYD R0PU H.HAND•AIJ0CFt,OTHER') Q 0�3TRUCT!ON(rtMr�eto type t»Igy) �n <br /> ,40IL BORING K_ R, gVLrR-laORE <br /> p welt.* p Pa�ssva���v�.'T <br /> •Othor; Gil SpedficAtiona - - <br /> CUMMENYS: __-- -- <br /> tzP of VYt:LL INSTALLA71e1114=C9 pol+4TRUrnQN 3VggilNI3 to <br /> A� <br /> p MON170RING a HOt,LOW STEM DLA.OF 5oREil 7.=MULTIPLE CASINGS?Q YES 00 WELL CASING 01 . ! <br /> a ExrRACT10N 0 AIR HAMh1EFt/0FtIVEN CA91NO THICKNESS I'J TYPE OF CASING'. a STEEL d PVC q OTHER: IJ, A <br /> Ll vAPOR o uUD ROTARY of PTM OP GROU i SEAL b 5 .TREMIE TYPIl USED: C AUGERS kHOSE <br /> Q AIR SPARGE el POINT GROUT SEAT.PIMPED: eea p No (NOTE: MAXIMUM FREE-BALL DEPTH IS 301) <br /> BOIL EOF+ING a HAND AUGER GROUT SPECIFICATIONS: �.y� 4- _ <br /> p OTHeR: <br /> OTHER _ APPROX. BORING DEPTH� Q BOLTED TRAFFIC BOX or u$70VE PIPE <br /> CONDUCTOR CASINO PROPOSED? IA_ (If YES.Nat,speC flGattom%here)' _ <br /> 'COMMIll <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT V 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 San Jvpquin <br /> County 0dlrll Hulas ll RegUletlons,and tell applicable Caallfornis State Lews. <br /> Scpnudx L;;� _ Tiile/Gartpany ✓ Lf- A "7^aSQCIO�V <br /> pent Name D f't`N Qv1 Data 1z� 'z'1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNrT N FILE,ADDRESS. <br /> WORK PLAN DATFq: <br /> Applicmloo Aceapme.®y_ Daef layuedG �__ _Arta► _ ______- <br /> Grant Inspection 9y_ Date F1npl Inspactlon 9y E)aw— <br /> r)eetructon Irq, ection 5x Date <br /> COMIll/4;ONDIr14N3: <br /> ACOQUNTINC ONLY: All <br /> PE GOUTS Y FEB INFO AMOUNT RGM1'TTOP Gt1l P REC10 BY DATE 0 INVOICE <br /> 9/27/40 <br /> C-.57_ WG„„ -WA;VER_ C-57 Lill of Authorizat(on to sign permit chtrent doC� <br />