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1Jun . 19 . 2003 5 : 05PM `'"CONDOR EARTH TECHNOLOGIES-" `" ILIJUM No 4022 "P- 2/2` <br /> WELL PERMIT APPLICATION FORM SITE .�..._ <br /> plr r, MITIGATION <br /> U ISDAAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES {�!Y!V <br /> ,;UI'� 1 8 200 ENVIRONMENTAL HEALTH DIVISION (PHS-EMD) u <br /> _. Iv <br /> 304 E. Weber, 'Third Fluor, Stockton. CA., 55202 <br /> J,V,i',)NMENT HEALTH (209) 468-3449 <br /> PZ--;U 1T/ISEmus NON-It1=FtJt�DABI�F^�k1Yr EVIRVt I nAA PROM DA'YE IISSUEC� <br /> Apptication is hereby mace to San Joaquin cvunif fcr a permit to consmuct an(var Instal!the vv"dascribsd: Thta application Is mads:n ccmoonaa with son <br /> )oa4uin County 0ovtlepm8nt T1119,Ohalster a-t 115.3 atr3 the Stancards of San!oaquir,Courot+y Public Health 5ervaces,EtnArcmmantal Health Dr+rlsfon. <br /> � <br /> ftyerr ADtie►34rs <br /> WELL Location., i:.''• L. pas--- Cross Slreet�ft }PIty L&Eti�Ql, Zip _Paa^Goti� W <br /> PROPERTY Owlet Ii-F;; t <br /> C•S7 Contractor e a S}�_i��ldresa�._� �- .'Y.,,.��Ci�,�i 0 AAJ <br /> j, , <br /> CwmytarAISub Cantrads CANb*FL _Y__ __�Addrv..ssl � &&Nf � !>CK'CO ,T �ti.rafH���dL _ <br /> Ggs cooroinate.'s:X� Y —__ ,TevJnot0--LS'".�.^�� <br /> WORK TO BE PERFORMED; <br /> krN*W WELL I BORING(CPT,r3f.OP;vets hN'0-'OP INCH,HAND-AUGER.OTHER") 0 DES'rRUC-110N(&Ocse type below <br /> 1)SOIL 90RING F � �� �.�.� d ovvik-SorE <br /> U WELL#--- Gk"CuT <br /> 'O <br /> COMMENn: <br /> y�n£.Q�WELL 11957FALLATION TYPE CONSiTRif TION SPECIVICAVOIKS <br /> Q rVIONr(ORING U HOLLOW STFIvi i!NO WML CASING 0IA:, _-- _ <br /> Q I XTRAcro+v q AIR NAMMIRRIOP.YVEN CASING YMICKNESS___r__TYPE CF GP.StN3_ 0 STEEL p PVG 13 OyHM'�- <br /> 3 VAPOR fjMUD ROTARY DAF rH OF 0R0UT 9F.At.__,TRENVE TYFIE TO 9F USED: 0 AUGE S II HOSE <br /> u Alfi SPARGE Q PUSH PINNY GRovr sex pumpm a-yea p NO (NOTE; MAXIMUM FRUIZ-FALL.,.DEPTH IS 30') <br /> �,GiL 80RING U HAND AUGER 3R0VT SPFCIF)CATi0N& 14,04LIr 'C .frftj 16 ik COAMN Umth <br /> 4 0THEf2;____,V0.T'HFRh10LSC--V APPROX,BORING DEPTH__ • 11 gocr440 TKAF1910 BOX or u STOVE MPF <br /> GONDVC"TOR CASING FROPOSS01 ,, ^(If YES,list;apedEcatlorts h®reX,---„_„_Y_� <br /> NOTE; OFFSITE SOHINGS REgUIRE ACCESS QR ENCROACHMENT PERMITS. <br /> �.� . CALL.THE UNIT IV INSPECTOR 4 WORKING HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared NO application and that the wvorkwill be done in accordance with San Joaquin <br /> County 9A"nces'Rules nd Regulations,and all applicable Califarrti;a State Laws. <br /> Signed% <br /> Print Name _ <br /> DEPAI~tTU N. USE ONLY_ �- <br /> SITE MAP IN UNIT 1V FILE,ADORE3S. 0 , <br /> WORK PLAN MATED' 15 f'{,:ED C �- �-�-�--� <br /> Application Aeceptsd 91 —n a"- r Clete Is3ueo— <br /> GMAIM10actleftBy�_ oat,�I Q Flnallri Peaen8y <br /> Destruction inspection By Grata w , <br /> COMM"T8 I CONDITIONS: <br /> ACCOUNTING ONLY- AID# <br /> — <br /> PE COORS PEP-INFO AMCIUNT R"j "ttD { Ct vcx* REC Dy DATE: — I PERMIT!6ERv.lCE REQUEST A INVOICE <br /> spa <br /> C-'57___,_ WC WAxV>=R-__ C-57 Latter of Authorl=tion to sigt^ pQrrns't,,,,�, EntroctCF17lent dec_ <br />