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10-24-2000 03:40PM FRO - TO ` j 15306766005 P.02 <br /> f�� F11 <br /> �C �WE� WELL PERMIT APPLICATION FORM <br /> SITE <br /> AUt; 16 2005 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> ENVIROWNrENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> PERM�TISERV"A TH 304 E .Weber,Third Floor, Stockton, CA., 95242 <br /> (209)468-3449 ct�� <br /> t "42FUNRNU MWIT EXPIRES 1 VAR FROM DOTE ISSUED <br /> Application Is harsby Me"to San Josquku County for a permit baad/arconstrud tl the week desalted. Thk appkedon Is made in coroptianos whh Ssn <br /> Joaquin County Dvmbpenent Title,OwW 9-1115.3 and the Standaft of San Joaquin County Pubeo HeM SON1006.EWronnmtat Hunt DWhdon. <br /> � rst �- �WILL L�mfto� S � RS�iw ` <br /> 9 5 <br /> Awl 0" PP..5820 <br /> C4?C&nazaor vi <br /> caaubnttsrh7 Phone <br /> 5 ►7h.�bZ <br /> +aISC4ordinshm Y 55° >3snge . soodw— <br /> lk"E"ELLIDOPmC t3# <br /> p DESTRUCTION(ch oosiRebeoN) <br /> FdB#R <br /> BI tpT1 PREoRot <br /> T <br /> � ids <br /> ijj MONI7ORIWG Q HOU i iW f3TEM DIA OF -1dEpple E24_MULT5"CASWGS?{J YES.p NO W Et1.CASING DtA <br /> d fl OVAt"TION p AIR CASINO THICKNESS TYPE OF CASING: 0 STM p PVC 0 ETHER: .. <br /> VAPOR p MUD ROTARY, 08"OF MOUr Q O '1REMIE TYPE-rO BE USED: p AWER3 ` � <br /> . E AIR SPARSE w POWs GROW MAL PUMPED:`,�Yas No(NOTE: MUM FREE-FALL DEPTH It 30 <br /> p HAND GROUT SPECIt=1CATK3N3 ... <br /> Q APPROX BORNM DEEM BOLTED TRAFFIC SOX or p STOVE PIPE <br /> CONDUCMA CA8MPROPOSED?. C! (if YZA,tlst specitl=56nsn harry <br /> NOTE: oFF3iTg-SopwaS REQUIRE ASC# OR ENCRCM WC MEW PERMITS. <br /> CALL THE UNIT IV wi : OR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> !ha sby earthy that I havo reel this <br /> applit.ation and that thework will be done In attaordarlce with San Joaquin <br /> COWdy an%and all applicable California State Lams. <br /> rutleiCortpary <br /> PiYet Name /"' Date <br /> 8rM MAP IN UNIT IV FILK ADDRM: <br /> WORK PLAN DATED: n <br /> ApOkstieft A ar Date lasteed -17-0 5 Area--5� <br /> Of" 0n DMe Final Inspection By Date <br /> OUMSOon kypeotlon By DIM <br /> cOMMOM/ NomoNs: <br /> ACCOUNTING ONLY: AI <br /> PE COOES FEE NFO AMOUNT REMITTED CHECK# REC'D BY DATE PORM17!SERVICE REQUEST# INVOICE <br /> t IgUA $ I 6 <br /> C-57 WC -WAIYEiL— C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br /> TOTAL P.02 <br />