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08/15/2000 08:18 WATE ^F_VEL0PMENT 4 2094683433 N0.079 D02 <br /> -II- IH I-Luuw <br /> 05/_512000 "a:21 305G6 33 FIFTH F1_;"AR �� c� 22 <br /> WELL PERMIT APPLICATION FORM = <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION{PHS-END) AUr' I 1 Zd�O <br /> 304 E.WII Third Floor, Stockton, CA., 95202 CT A!fllv?E;JT <br /> (709)468-3449 PCS^Air/gE yEALTu <br /> NON-REFUNDAWA PERMIT EXPIA Es Y ON CAT 55UE0 0 <br /> -Dpuea9pn mmereby miI San JOaaem County kr a Mltriit ro een]:rup1 artlfor im I the wo nad11CM. TO!"P0'K" "la r-+ade rn¢r,olran�xt <br /> San_m Quer Cc my 00velopnprt Tye,Chapter a-51 t&3 a•+d tme Standards cf San JOIIOubI 004111Y PWI ISG Healtn Semau.Em� <br /> WEL-Ltion 2115 4t 945 d ear s s <br /> � lx- D Chr, o�S37 4 arx� 8q-10C-r%Y <br /> p. Lf..1 aei._lSf ^ lcvEud, �zetia �� ` %nvao <br /> PRCPFIrro:merrb-Ra-+est-�-.-+ 3 <br /> csr c ntr6o rO pkJ�+Add,,s dol 1 Ke,5 Aoc. _CjI _ z P 4577fP <br /> 4 <br /> Carotrlfalrs f suo Contra= 54ra A'.« Gn_ .__IIx ar:oras 53G- '16 <br /> `ul5 laatimaYs:i` y <br /> .Y__..__J„__ --_,Tgwes p RaW °eG vt <br /> WORK TO UTPERFORMED <br /> GORING f CPT.GECPR08e.wYDRO NCH HANO.UJGFM 0THER'1 Q OESTRJCTION(00tyaa Qm-X <br /> QV--K aORE <br /> y�OiL BtlI21N3 s Y1' Q PRESSURE;>ROV= <br /> WELL a <br /> "CYUror: �x <br /> CCMNENTS; f+{ fD I T I V is �R.Y• 10 r., <br /> TYPr OF WELL INSTALLATION TY DE CONSTRUCTION SPECISIDATIO S (�h <br /> )&IQ TORING D H c1W STEM DIA,OF FOREHOLE I�,QMULTIPLE CASINGS?0 YES 11040 ALL CASING Z;A'__ <br /> if EXT RACTICN )vWtq HAMYIERIDRf,-.N CAS''.Nu 7NICKNESS TYPE DF CASING: O STEEL ;50v0 0--'Tr4ER. <br /> a VAPOR D MUO ROTARY DCpT•H OF 3ROL"T SFA: UA TRENBE TYPE TO d=USED. 0 AUGERS $F4.^.SE <br /> Q AIF.SPARGE O PUSH POINT GROJT SEAL RUMPFD,$t•C U ND (NOTE: MAXII AF FR FREE-FALL <br /> L' 0 DEPTH C TE P 30,) <br /> '� INC GILGOR0HAIM AUGER APPROX,EiORINGJEVrH W <br /> O OTH°,R: DOT/+ER CONOJf:TOA CASING PROPOSFOt I�_!If YES. <br /> ,Istt=�ocel�:ipnIs mare) / 1111 <br /> cOaelCHtf5_ SR ', u t - L -- <br /> _... O <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESSESS OR ENCROACHMENT PERMITS <br /> I hereby trrtlF;Mat's have oraPared Nis aPPli0ati0�aad th:n Re work wtl'.be dais In acCitlanc11 e nith San Joeque "W OnHn pg ar Lars apo R: k <br /> and P.agvlatione at the 38n JoaQuln County. Hamcewfe¢r of I�Cenaed agJ'1f9 slBna[we Gsrtl�q Ins fplOYrinO;"I ee+Efy Inat v 21+e Pelf�'�e�y=w•�` <br /> for wnlDn arrc Perth,!/s::aaad.!:./volt not employ pemsdnt;FvhI to WOANP.PoS'CCWp,%VSAT}t7N Laws of callfe„+ra.' C.amYJeC 6 <br /> caritmWlrg signature wrjlln%the fallewina:')mroy Nal�r,Infi <br /> fine*OrI,WAekclrfib$pfiandI:iF,✓Bd,fanal?e^_rJayPRII4n:f <br /> WOn-KERS'GOndPENSATICAf laws of CaEf9rnla' UIREOd <br /> cALryL',:TQE` Irfil . . V"tOR.dB-yVD[I_ I5IN1►1311JkrWlCE'FR .: .. �1 r1.ONS' <br /> SC4t+ afCnPany Jr�19 �J 5� /!�4N6 ✓ o <br /> 3!gnOC /% L46'� <br /> vrlm Name SCD �' ^ J ' DD:e 6'2A*4P <br /> pEPARTNENTI!$E ONLY v�115`�� /+re4 <br /> ADD+cetinn Accepted BY q •i" �Faat 1"4pee+m:.6Y Oft <br /> Grout 0y �7at0 <br /> Oesrumm IUDCr:Yron$y 70tC <br /> CONUAENT$i CONQWONS: - <br /> r <br /> 1 ACC CU TIN G 9N LY: Air.)* _ <br /> PE COPES GEE Impo AMNOUNT RENGTTEO CHECK A { FI BY LATE I; PERMrt I SERVICE REO'dFST a INVO{CE <br /> s o6 DD�3-73 <br /> J r:e;zxo <br />