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flax-20-2002 03:17P FROM: TO:19.163834084 P:2/5 <br /> j r <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> I ENVIRONMENTAL HEALTH DIVISION (PHS-END) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209)488-3449 <br /> kppForGon is hereby mass to San Joaquin County IN Is POMM fo oenabuel srtd/ar tns401 Mie-oft 4ascdbed. TNv oppltesaon M made In cornpwnce YAM San <br /> loaquin County Dsyskn~t Thio,ChopW 0-1115.3 and Im SIWK%rda of San Joaquin Comyr Pubfld Heaph Services.QnvironMental HOOM Division. <br /> s1(s ZA � W*vV0g%O6s a 97N �t52Zo Atsesaors <br /> IVELLt-aeatlon Cro»9treet G'!y AcR� zn. ^P�xttr O/y-o9-oot� <br /> PROPERTY Owner fM-efte 'L'rv— Ade»a ' G tea (20 CityQWVSiof Zip�`�Planei! <br /> a-sT Canbsclorl;xK fsw�wo,.s+w�c Aoasss 39� Sµstc�s tE pn,f(i1 Qs23Pnanaai 2O`i 7lt-3590 <br /> ContuBartt/Bub Contndor'D6 L- 29 AddressJ' 113, �� cllY Go Lit�G'Z«—�2►o..PAorlof j i Uf-dy)'L . <br /> GIS Owdnstesr X .Y� - _ .TMM"p fA Son" 75F Section 1/ <br /> YYOiiK TSD sE�RE�3Mti[� ' <br /> ANEW WELL 1 BORING(CPTP1=08E <br /> 8130 .HYDROPUNCH. 4AND-AUGER,OTHER.) 0 DESTRUCTION(choW6 type below) <br /> i3 M■GORING* ,D T - f d p OVIEER490RE <br /> Q WELL a SPREMAE GROUT <br /> -Other. Grout Spoeifleellons- . <br /> COMMENTS-. <br /> TYVE o�Wfu, iNSTauATt�DaI TryE �lslrRu_aTwtt sP c1FicATtoNs <br /> D MON"O"a p HOLLOW STEM DW OF 90M"OLI!_MULTIPLE CASINGS?BYES 13 NO WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAk M FWRIVEN CASING THICKNGSIS TYPE OF CAaWO' p STCEL Q PVC C OTHER; <br /> 0 VAPOR Q MUD ROTARY Dr;PTM OF GROUT SEAL TREMIE TYPE TO SE VWO: U AUGERS II H03F <br /> 0 AIR SPARGG D PUSH POINT GROUT SUL PUMPED: Q Yes p No (NOTE:MAXIMUM FREE-FALL. DEPTH IS 30') <br /> p SOIL BORING Q NANO AUGER GROUT SPECIFICATIONS! <br /> Q OTHIPt. U OTHQR APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YEs.Ist spegriCauafo herv); <br /> •COMMEItTs: <br /> NOTE:AFFSITE,B NGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> 01hymt <br /> HE IV P R+�WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> t 1 h e red tills application and that the work will Ire done In accordance with San Joaquin <br /> s, * d equlatlons,and all applicable Callfomle State Laws..r► Date S- 01 <br /> DMAWMENT U ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Appkaftn AtCtptsd 8Y Oata lot 'J ,� ? Ares <br /> Grout Inspecson By tato Final Imp*~By Date�� <br /> Inpectim a sy Osla <br /> COMMOM/CONDITIONS! __ ■ <br /> A000 NNTWG ONLY! AIIX SAIniv <br /> PE CODIS FER'MyiO AYOiNtT lt1:MRTED CHECKS RECD 8Y DAT[ FERMrr r 3ERViC AEQU29T t INVOICE !-� <br /> c� r v <br /> C•57� WC-_-.=WzvEA _C- Iter oAythor t r, it Ictoachrnent dor, 9127/00 <br />