Laserfiche WebLink
07/27/2001 13 44 2094683433 FIFTH FLOOR PAGE 01 <br /> 1 � <br /> WELL PERMIT APPLICATION FORM SITE <br /> _ _ <br /> MITIGATION <br /> �� 3LIG HEALTH SERVIG S UNIT Ill <br /> Past-Its Fax Note 7671 -7,-401 196 j{ DlVIS1DN (PHS-ENI f <br /> _ <br /> From <br /> To {'LLQ dc-t ac t~ Stockton, CA., 95202 a <br /> _CoJDOOLj- ETf COS C- l) .3449 JUL 2 6 2001 <br />' Phor►e if Phone 0 zJ011 6c`Sb�3 <br /> Fax 0 i _s 1 Y�he irk d scribeATE This 3p Lance War, <br /> Fax S Q Z 1 S0 9-K ins oa the work described health <br /> a <br /> a air.taaquln County Public I-lealth 5 Ith t]wLaIon <br /> -05 <br /> LLocatlon 1645 Cherokee Lane Crossstreet5ai' uinett1cdyStockton Zro952S--�Parceir i1g466�b9Z7 <br /> OPERTY Owner <br /> GA Traction Company ,Address 2201 W. WashzngLonc�t�tackton z,p 95243 phane�209 <br /> 5-8712 <br /> nsur -5205 L zS12 �_8Pnone 09 ' 21.57 Cantractnrddress 2365 W3. wam prive C46tockto0-521-2684 <br /> itant!SubContactorHydro—Env. Tech. Address 2394 MarMS S9_Cqkjameda L,el /A phone#51 <br /> Suite 2 21� Range 6E section 43 <br />■s Coord�ates x 4204400 mN ,y 652404 ME Township <br /> RK TO SE PERFORMED <br /> �j DESTRUCTION{choose type btio.11 <br /> V <br /> Eyy VELL 1 BORING(CPT GEOPROSE,HYOROPUNCH, HAND-AUGER OTHER-) l7 OVER BORE <br /> Q SOIL BORING# Q PRESSURE GROUT <br /> J1 VVELL 7✓ — <br /> ther <br /> COMME{rITS i <br /> F WELL __, Lt ATlOA1 TY?E CONSTRUCTION SPECIFICATIONS ' O WELL CASING DIA 2.0" <br /> OLLOtN STEM RIA OF BOREHOLE g. MULTIPLE CASINGS 0 YC <br /> �N <br /> ONITORING SC� h 40 <br /> EXTRACTION d AIR H0.MMEQIDRIVEI�t CASING THICKNESS TYPE OF CA51tVCa Q STEEL PVC 0 OTHER <br /> HLSc <br /> VAPOR 0 MUD ROTARY OF-PITH OF GROUT SERL 10 fit: T'REDh[E TYPE 7D BE t15CD � AUGERS �} <br /> PUSH POINT GROUT SEAL PUMPED x]Yes �No (MOPE_ 1Vll>XIMt�i�i FREE-FALL DEPTH 15 30=) <br /> AER SPARGE a <br /> HAND AUGER APPROX SOigING DEPTH 50 f t ]j BOLTED TRAFFIC BO <br /> or 0 STOVE PIPE <br /> g SOIL BARING Q If YE5, List specifications here) <br /> OTHER Q OTHER- <br /> COMMENTS <br /> CfaStiiG PROPOSEt)? Np { <br /> COMMENTS � OACHMFNT PERt1 ITS <br /> NATE: QF�51TI" BQRINOS REQUIRE ACCESS OR EN R <br /> I hereby ce,t;;'y that 3 have prepared this appltcatiort and that the work Will be done t>n accvrdanCe� ith San,loaquim <br /> County Ordinances,State taws.and Rates and Regulations of the Sara Joaquin County <br />' V GE FOR ALL. REQUIRED INSPECT'N Tri Aire_ <br /> THE UNIT IV INSPEGToR 4$SNC?RKih1G HRS IN AD <br /> Signed x <br />' Pani Nwne <br /> Cel, Date <br /> SEE SITE FSP I UNIT tiff FILE WORK PLAN DATED <br />' PEPdRT'hhETtT I]5E DAILY gtea_.,_�.-.. <br /> pate Issued Z G <br /> App4raUon Ae=pted By Fina]In=pschcn gy Date �� <br /> Great Inspectlort By pate <br />' pestn,d]¢n Ir,apaehan B]I Oates <br /> &l1�ENTS I GOAI>a1'i30Pt3" <br />' ADCC3i w INC OKLY: A C># c <br /> pE CoDes FEE 1tdF0 AMOUNT MIA rYED CHECK IES sRz:c'a BY DATE <br /> PERMIT!SE�iVICE REQUESTS IhtVGICc <br />