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12r29r00 FRI 13:06 FASZ 003 <br /> a -� FIFTH FLGOR PAGE 04 <br /> 12/29/2000 13:38 20,468' <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 Moor, <br /> or, Stockton, <br /> ton, CA., 95202 , CA <br /> T � �tDUr '7'3y� <br /> N NDA <br /> IT ex t YEAR F is <br /> AOPllwSsn is nrxeby made to San JosQuin County for a Pal to construct wil inni I"work deffoHe r al, Th <br /> rvicesa Ill�En�rrrnmantel Hill IDMIllm.h San <br /> nt San Jo apkr 9-11153 and the Standal of San JoaGuln ColLp�u�/ Assessors 'p y-X3 -00I <br /> Jcaqun county Devabpr!'se -Dar• '�'.p! ZIP ParcelN 10 <br /> oss Street cJ CIH��� a ,O—p <br /> WELL Lou{ian_ -- ��,� � S µ=-C e GL. Phone# <br /> ass 42.0 r'"-C b ' I ��- <br /> PROPERTY Owner tP L;pr '��'JERonk11'-�fiN=B-y..z�Z <br /> C�tY / <br /> C.57 Contractor, � <br /> mss CIH <br /> Censuhant 15ub Contactor Section <br /> GIS Coordinates:Xj= <br /> YJ ToWnship� ,tange� <br /> W TOB PERFORMED: U DESTRUCTION(drool.tyPe bele^') <br /> MIrILL I BORING(CPT.GEOPROBE.HYDROPUNCH,HAND•AUOER,OTHER-) U pyER.BORE <br /> n SOIL BORING# n PRESSURE GROUT <br /> 1]WEU.is Grout SpecfSntions: <br /> -other: <br /> COMMENTS: \ <br /> t(PE OF WELLAL`T L^TI��N TSE Go-or BOREHOLE <br /> LE <br /> N 4 r/. <br /> J'' PIA.OF BOREHOLE MULTIPLE CASINGS?O YES 9(NO W ELL CASING OIAA- <br /> MONI-ro G �IIOLLOW STEM c TYPE OE CASING: 0 5TEEL �C 0 0THER: <br /> r_AIR HAMMERIDRIVEN CASINGTHICKNE-S REMIE TYPE TO BE USED: Q AUGERS 0 HOSE <br /> F_X'(RAG710N 0 DEPTH OF GROUT SEAL���- <br /> gVAPOR 0 MUD ROTARY y� Na (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> PUSH POINT GROUT SEAL PUMPED: a u O <br /> Q AIR SPARGE GROUT SPECIFICATIDNS. <br /> n SOIL BORING 0 NANO AUGER APHROX-BORING DEPTH U BOLTED TRAFFIC BOX or*STOVE PIPE <br /> U OTHER: n OTHER it YES,list sPearlcations hee);_._---- <br /> CDNOUCTORCASINGFftOPOSED7 i <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> FICTIONS. <br /> CALL THE UNIT IV INSPECTOR 45 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSP <br /> I hereby certify t I have prepared this application and that the Work will be done in accordance With San Joaquin r <br /> County Ordina .Rulas Regulations,and all applicable California Stateaw� <br /> TiUdGomperH �/7��,.� <br /> Signed t Oare ZQ L+�� <br /> Print Name PARTMENT USE ONLY Y /9r-190-oo(r oo f <br /> r 30 . 02.E 07-3 031 <br /> s <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> D <br /> WORK PLAN DATED: 03 <br /> Y(3�(OD Arca <br /> Dale Issued Dem <br /> Aaplic Pion Amil BY Dau Fnal Inspel By <br /> Grout Inspection BY <br /> Destruction Inspal By <br /> COMMENTS I CONDMONS: <br /> ACCOUNTING ONLY: AIO# <br /> PE CODES FEE INFO AMOUNI'REMITTED cHECKB RECO <br /> BY DATE PEZZ <br /> REQUEST# INVOICE <br /> 702 5 <br /> 9/27/00 <br /> C-57_ WCC W,aI1lER_ C-57 Letter of Atithor�i2ation to Sign Permit_Encrooci'Iment dot_ <br />