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hWY-20-2002 03:17P FROM: TD:1ylbSti.S4k=" r•�"•' <br /> I . <br /> WELZ PERMIT APPLICATION F84M SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-END) UNIT IV <br /> 304 E.Weber, Third Floor, Stockton, CA.,95202 <br /> (209)488-3449 <br /> DATE M3 <br /> tDplb.6aet h fferetyy rnaoe to$an,baquln County for a pentut b oerra4uel ene/ar insraN the doratbass. t eppliptfon h made in eotnptNMa �San <br /> foe in county Development Tide,Ch*V a a 1115.3 end the Standords of San Joaquin Counh Publle Hooch Services.CnAronrrferttai Haatih Division_ <br /> ZA (.leoaAR�Cb� N �152Z.o Assessors <br /> NmLoCetbn y6 Croas9treet aw Acrd° 2ip_5_ ALSessoes -=q-cot. <br /> 7110lERTY Owner N ex �S,s AQOrea ' G N1 a Re City t.lvoU0 ZIp Pfenell N <br /> .1-57 CahftdorT- l Yd Y' 'as CIA'3` �Zb ks — --fah° - <br /> ConsuMant,SSC ConNaaor'A L-BNeeew R r: -Addresf jttgM !3 ery_4LW Uao G'Z.� 13!o Phontx !!30-ef'r 2- <br /> GIs <br /> GIs Coordnates.X .Y ,Totwrghip RsnOe 7f Section_! / <br /> WELL 18 R1NO(CPT,GEOPROBE.HYDROPONCH.kIAND-AUGER.OTHER*) p DESTRUCTION(chose"Wow) <br /> ASO4 BORING w D l 1 b p OVER4ME <br /> U WELL N SPRESSUME GROUT <br /> 'Other. Grout SpeaiM gnsr <br /> S: <br /> �+���. -.�+� � r�����s-�� �•r�.-ter <br /> Tr a yL IN PIutTwt+'►; SQNttlrRyUG=sF Ic�� <br /> Q MONMORtNG Q MOLLOW STEM DIA.OF DOREMOLE.MULTIPLE CASINW. Q YES C NO WELL CASING DIA: _ <br /> U EXTRACTION a AIR HAM MPMRtvEN CA*NG THICKNEss TYPE OF CASWO: p MEL p PVC ()OTHER: <br /> Q VAPOR 1)MUO ROTARY 0817TH OF GROUT SEAL_TRI MIE TYPE TO BE USED: Q AUG ERS 0 1,103F. <br /> 0 AIR SPARG@ o PUSH POINT GROUT SPL PUMPED: 0 Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS! <br /> Q OTHgR.,_U OTHER , APPROX.BORING DEPTH — �D BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSsO? (if YES.11111110042601"herv); <br /> ,COMMENTS: <br /> NOTE:AFFSITE B NGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> ohny <br /> H IV P R 48 WORKING HOURS IN ADVANCE FOR ALL R9CUIREO INSPECTIONS, <br /> t I h e red this application and that the work will be done In accordance with San Joaquin <br /> , d eyulatlons,and all applicable California State Laws. <br /> Tluc/Cvma+ny.�hNAias. oP G ►uHR�S -20 <br /> alive <br /> �T <br /> DEPAWMENT U E O LY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ __., - — <br /> WORK PLAN DATED: <br /> Application Aocpteo By Oats lanled�c Artie <br /> Grout tnspeceon By Data FMiI it"ection By Cain <br /> Oesteuation In By !}ata <br /> COMM6NT8/CONDRIONS: <br /> ACCOUNTNG ONLY! ADM <br /> PE COon FEE INFO AMOUNTREMITTED CHECK d RECD BY OATl: PtJtMR/3ERVICE/R�Et3 ST f INVOIG� <br /> c� IKAA / I v <br /> C•S7',_ WC -WItIYER C, 71�tf�r oAcLhor t n EticCoachment dvc�_ 9!27/00 <br /> i <br />