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11/ZV/ZUDD lb:4d 1'jlbbd8nbl i. UHbl:AVt 1JKILLLNU INU __ YHUt od <br /> -. .....'a: c m <br /> 14,041 ORIGINAL <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> UNR N <br /> ENVIRONMENTAL HEALTH DWION (PHS-EHD) <br /> 304 E. Weber,Third Floor, Stockton, OA., 95202 <br /> (209) 4683449 <br /> bo-NAUUMM"PERMIT O(PrtEal t YEAR FROM WIT!IpUl37 O <br /> Appgomll n b hl by made to Can Joacun CpuntT fora pemit to eMr "ardor kwhilt fr wn datolb•d. Thb aryeorbn leNanta h trarldlarlaa aM�afl <br /> JopurT Count'thQy�dM�p�rroM Title.Cnryer 9AA1116.3 be 8t+n.�erda o}/�84 JugWn MV"I-Meath 6•n{a•,fnvk*r rAntm1 F4fft Dhhlee� <br /> WEU Lucston Q b UOlh I)S�z_��Yt if, � crwa )guest l.lM'1.421 /L�O��F /LAT1tC�?Lp 33i> Pen <br /> PROPER C' tar()J r?y 0'-- (../-1'RteoL Addm,l G ql)� `L{C�A�Iwa L,4T)ei,�o Zip S� �O <br /> e67 Cen72= ' y--Lty_TPN/Jr-, 41 !'�e+a/ <br /> y� �d QLP ibZ1�2� <br /> CotYYldre i Bub Ccnvarta'3;T 111o,P =1� r1�11.LT A.Vd>m ✓It:IU Upr ft..N 9dw-Mix-3 <br /> OM ComQvater.;x_ Y .Tv+wWlp Ranpe eedbR,_,___ <br /> RI T <br /> E'+Y W ELL l B^11VY.J i CPT.DEOPRDLE,hiYDROrL1NQi,1 WtD-AUGER-OTHER) O D[6T VKJ"CN klroa•a We bal-4 <br /> D!PL aORWO a ()WEr-e101iE <br /> ELLa_ 8 - 0 PREIII RE GROUT <br /> r. <br /> 'othe :gad spedecaeo+.. <br /> COMMEh-r& <br /> '='p OF WELL INXLAILATION 9 G9mm EN1I <br /> -)jQM.7NROhi1NG LOW$YETI CM OF 60R6faOl.E MULTIPLE CA91N0.'!7 YE3 y`('�O WELL C.�MVD W�,� <br /> B EXTAACTION 0 AIR HAAw WORIVEN CAGING THICKW"Sup- V TYPEPF CA84NO. D STM `{E4vc u OTHOtt.— <br /> D VAPVr 0 MUD ROTARY DEPTH OF OROt1T SEK TRE..TYPE TO BE USED:. GAUGERS ONO" <br /> a AIR SPARGE OPUSH Pow 3RdJTSEAL PUMP®: Gyn -I.j`+o (NOTE: MAXIMUM FREE-FALL DEPTH 1330') <br /> 0 SOIL BCRING n HANOI AIJGEP GROUT SPECIF"TI <br /> OTHER n QTHFIt_�., APPRO7C BORING DFyTM OLITil TiiAFPIC aCJC w 17 BTpVE PIPE <br /> CONDUCTOR CARING PROP'OSEDT_IS1Q I IrYED,14t•pedilOatbA Meal' <br /> coMMe+Ta: <br /> _ NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORIUNG HOUR6IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have pr•perad this application and that the work will be done In accordance with San Joaquin <br /> County Drdina ulna end Regulations, end all applicable CaUfornle Stab Levine.Lel` 9 <br /> sMR� �+ Tl7acxaponr �� / ACL 4� �r/ �/i nJ <br /> Pint Name G�' G M Q. ✓t <br /> gEPAR I t;n 1 U35E ONLY <br /> SITE NAP IN UNIT N FILE ADDRESS: <br /> WORK PLAN DATED. O <br /> W W W a <br /> Ym AaD7ed 9Y tr baled Ana <br /> 3l tlnapeclm By I —Deme—pow"nape'*M er <br /> kwkmb <br /> Je•vn Inap�ian <br /> exaMDoti. <br /> Nai <br /> :ocNTs rcoNDrrgR. <br /> t-2i"Z Ci r:_ <br /> ACCOUNTING ONLY: AEN <br /> PE CODES PEE tNFO AMOUNT RBIrr MD CHEMO a RECD BY DATE P[RMfT I SERVICE RIQUI ST a I11Vt71GE <br /> C-57_. 1VIC=WAIVER_ G-57 Letter of AmAherizetion to s gn permit __ Encroochmsnt doh 9/27/00 <br />