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JUL-27-1999 11'13 P.01 <br /> WELL PERMIT APPLICATION FORM ED <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIMON(PHS-EHD) J U L 2 8 1999 <br /> 304 E.Weber, Third Floor, StockWn, CA., 95202 <br /> (209j4G$-3449 ENVIRONMENTAL HEALTH <br /> I+o M ED PERMIT / SERVICES <br /> ApplIC04 on is hog"made 10 San J"Quin Cbuety for a panttit 7a construct arwar roma ft want desaiW. This appit nicn is raft M compliance with <br /> San Joaquin Oourtti roa,chapter 9-1115.3 and the Maoalumr.01 SM-;=q in Counly Puollo rteeft St-k es.E"V~rntm,t Heatq+OtviSion. <br /> WELL Locerseo ?� Gtf�R'OKFx Lhl cross svi�~r 6v i l,.IEt'1'1 ii a l�r�Onj L'p Puram Assenots <br /> l�stC/t4 s2 2of W ?%v pt t/�A16 r.4tJ <br /> piRopER?VOwner C1+.'fi�.GC 6&jAddreas s,�.-r,i 12 City 9Tpc47oi7 Zip.9S2.� Prgnaa <br /> ConvacWj&v'W Lir Il��� _.�ddr.6E 9sn ,�Rt �b LfiLlTsEt+P..L.Tiir�►d�Palat+eCQ�.I-- ter - avo <br /> e0 �AOMS:oaart</Sub Cansar 9vrr -2 e 0—Cly G�4�r41^+st <br /> Gv Cootdinatea:z - -- 'Y Township Range _- —Semon <br /> WORK TO QE fItRFORME <br /> I NEW WELL i BORING(CPT,OXOPROQE.HYDROPUNCK It11ND6tUGER,07"01 11 DESTRUCT"(choose typo below) <br /> w.SO1LiORtF/G.f <br /> I0 Z;- 3 14 �� <br /> D yyELL 0 PRESSURE GROUT <br /> 'Olflef' <br /> COMMENT-: <br /> tM v tTP 7113 <br /> 0 MONITORING HOLLOW STEM Dain.OF sOREHO " MULTIPLE CASINGS?Q YES ■NO WQU CAStivt3 DtA: <br /> p EXTRACWN 0/UR"AmmER10MWEN CASWO THICKNESS_,.- TYPE OF CASING: U STEEL n rvC p OTHER: <br /> a VAPOR a MUD ROTARY DEPTHOF GM TReM1F TYPE TO BL USED: Q AUGERS Q"OSE <br /> ASR SPARGE a PUSH POINT GROUT SEAL Puwrc: t Yes 11 No (NOTE--MAXIIMUNI FREE-FALL.DEPIN 1S 30') <br /> p SOL SORING Q HAND AUGER APPRQX.BORING DEPT"• -f4,1 3u ?- Q OOLTED TRAFFIC BOX or 0 STONr6 PIP! <br /> p OT}�}l; OTHER CDNOUCTOR CA31NO PROPOSED? —(if YES,tial spacifcwtons neral: <br /> cdfdws: <br /> NOTE: OFFSITE 13ORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I IroabY oetlify Nat I ataYtl taeparad Otis appualtion W4 trial tM wa*nsw go bed naw"cvA�the following:"r corfffy Olaf;n M P es of tris—* <br /> and FgpuwuwA o1 the sae josayin Cornu. "s,"ev 'W W dcetlsad agenra sig <br /> naw" <br /> wn;cf�Otis panni+;s issaued,r sf►aY hoe a.t�pley parsons w6jact to►ems'COOPeWSAII Laws of CarMPOWa.^ eoaoacwrs hitit+g sw- <br /> oww"ting s14ratut!egnWm s Me foltotring:I oartJfy tnN th me Da"Wmanae of Me vloAc for wfTtch tT►fs ptmu7 is as++ed/sAetl sn>RI+oY persons�J�+le <br /> WORICORS'cOMPENSATRW La-c of caWb"08.- <br /> THE A PLICA ST CALL 44 HRS 1%ADVANCE FOR ALL REQUIRED INSPECTION& <br /> $g}flta k <br /> . ...SEE., .SITE...MAP. .IN..-UNIT 4V WORK-PLAN DATED <br /> OUrAATU9a USE ONLY <br /> Date Issued Z5S 9 <br /> Aoplicat+on Aeoepted•y <br /> D rs d_ q F;n*I Inspealon BY <br /> Gf"inspodion By oats 3 <br /> Oestrucoon IrtuectiOn ft <br /> CpMMENTi t GONOri10N': <br /> F <br /> AGGOUMTING ONLY. <br /> AID* <br /> CttECIWCASH R6CE> 6V OAIX pgWR TfSEmvVZREQUIMT NUtaISEI! IiiV01CS <br /> P!CODES FIFE eti0 ^mOt NT REWTTED Z O <br /> S o i 'e- - 5► .o 0 3 5 <br /> C„ 7 LICENSE,D CONT.LiA.CTOl MUST SIGN UCEN <br /> sa:'c40RBF.xS'COMp>ErtSipt.110 DECIAgA1TON <br /> UNIT XV-jn3.M ft ign biog/Ul <br /> 99x P.02 <br /> EJZ abed !Wg: 66-LZ-Tnf`•ZOEO Ete SZ6 `• 'ouj 16uiisas -a 6UTTT7.:o 86a,ag :As 1ual <br />