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Sent By: Toxichem; 510 595 1288; Apr-25� B:OBAM; Page 2 <br /> 01/10/2002 13:54 2094bd- rIr IH I-LUUx rain <br /> r r r i H r LOON Tb C'+ PAGE 02 <br /> C 6� WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) W <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-344y(;. <br /> NON. FUND& p R EIPI f EAR AT D <br /> Appucaoon,s hereby made t0 San Joation County lot a perm t to collstrud andior install ma Work rleacnbed. TIAs apP lawn is made u,cumdiiance Will San <br /> 1o00uio County OCveloGm0n1 Title.Chapter 9-1115.3 and the StandardS of San JopNum Cuvnly Public Health Se Acss.Eftwonmanlal Health orulsiun <br /> Aei4S5dr5 O4 2- <br /> WELL Location 3+r/'SAVV Cess Street City,S'IbClr: n Zip 520 Parcel# /41—tl3 <br /> 3SS <br /> PROPERTY OWn&r 0+il&r• E_, gntee �* AddreseN3_bQ_Cily Heaefs..'T)Qip�?31- <br /> 0 phone#YS.S-f MN^2 <br /> C-5T Conbauvr Address s� -City.Mwh;drXIPLiclr +/�j�Pnona#92S-31S"�'SEO <br /> Cunaultanl I Sub Cvntr+cror <br /> 'roXie IMS Addraas. iYo70Phoneir�{_4`SSI <br /> y Townsnlp_ —Range_ �._.—section_. --� <br /> .. <br /> WORK TO BE PERFORM ED: ESTRU CTION(rJoosO[yPe belew) <br /> gNEW WELL I BORING(CPT GEOPR09E,HYDROPONOH.HANG-AUGER VER•SORE <br /> Q SOIL BORING# D PRESSURE GROUT <br /> ,0011VELL# V2 <br /> ... ..,— <br /> GroutSpedfiwhuns, 1 '- <br /> 'Omer. r • a• <br /> COMMENTS: W— O VtJr'd 1^4 wG ,yr/r0�[, <br /> Waal TYP CONSTRUCTION SPE IFI'aAYIONS L <br /> TYPE OL E1,y 1Q�MU CYtpLF.GASII�S p YES 0 wFLL CnSwG Dia d <br /> vilMONITORING HOLLOW STEM DIA.OF BOREHOLE �[ <br /> V FMRACTION O AIR HAMMErUDRiVEN CASING THICKNESS SCh N�TYPE OF CAS)NG: D STEEL r0•VC n NOSF <br /> IVAPOR a MUD ROTARY <br /> OEPTHOFGROU7SEAL_� TREMIE TYPE TO 6E USED' QIAUGERS <br /> II AIR SPARGE Q PUSH POINT GROUT SEAL PUMPEO: V ye% VNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 34'I <br /> Q 500.BORING Q HANG AUGER <br /> GROUT SPECIrICATIONSI T <br /> 00LTED TRAFFIC BOx or YOVE PIPE <br /> OTHER APPROX.BORING )EPTH_LSr O �— <br /> CONDUCTOR CASING PROPOSED?-,�1,_(,f YES,Tial SpeuGcaliono here): <br /> •1�.Pk N <br /> -cornMENrs; � <br /> NOTE.: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTQR 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 JO4gJIn <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. 1• - <br /> /f \SP1- Yi[la/nemPany �Cr. <br /> S'cinsd w Ls us7�� <br /> 11 Dale !Z�~°) <br /> Print Name Zoss D pARTM NT USE ONLY <br /> USE <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_.� y� <br /> WORK PLAN DATED: �" �VIt , 62«7 <br /> Date issued <br /> ! o/0-A- Area_ _ <br /> Appbcation ALrvpled aY. Date F1nal InSppclipn By - <br /> OmullnsPeclionBy_,_ —Date <br /> UcSuuctlpn Ina aclwn DY <br /> COMM£NY$I CDNOIT,ONg' <br /> ACCOUNTING ONLV: AIG# <br /> pE <br /> CODES .FEE INfO AMOUNT REMITTEE) CHECK# REC'P BY DATE <br /> PERMIT!SERVICE REQUEST# WVDIGt <br /> L Jq. � / l 02- o,BsS'Y <br /> ' O� 60 Ed` (�3 horizo9/2!/DU <br /> C-57-_ WC_•WAIVER, C-57 Letter of Autfian Tn sign permit,Encroachment doc� <br />