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Vj02 <br /> 07/12/2001 07:15 FAX FIFTH FLOOR PAGE 03 <br /> 11/07/2001 16:09 20946E <br /> +1 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> ENVIRONMENTAL HEALTH DIVISION JPHS-EHD) <br /> 304 E. Weber, ThJrd Floor, Stockton, CA., 85.202 <br /> (200)468-3449 <br /> MINES <br /> ,ppRgtion is he""Made to Sen looqufR CMN 4 Pen*>1t to cDm*� undlor irS %im wort,dowtbed. To appiicat)on Is made in complhriae wifi Ban <br /> ioaqufn County DaveloPmern Title,Chaptar 11115.8 and 9V Standards Of San Joaqulrt C wW 10011C M"Ith 60n4OM Environmental t-lealth Divlaion. <br /> Aftegs&6f <br /> pr� <br /> WELLt_ r. wrl't T2�- ziP <br /> RTYGwasov1 M' Adesv �` <br /> :-57 cnrmcro1- u5�z► 5 'hoR 5 <br /> a 2Z5'L3- <br /> d <br /> Adde � <br /> :00*49tart/ 0"lubdo* l., LLIC s po(jolt g35y- '-Gh -u t o�+are 43826 <br /> 119 Coor,ilnebw X .Y Township Ranee SACdOn <br /> am M be PERfORML5� �DESTRUCTICW(ehoow flips below) <br /> (NEW WELL 180RIN G t�SOIL 60f�llN(3YDROPUTtGH.HANE1-AUGo=R.OTN1!R7 -XOVER43QRE <br /> 0 G <br /> 1i WELL tf PRESSURE ROUT <br /> �1or. t3cut 5paelfkativns• <br /> :QNlIiAEN1T9: o+� �— Oa opo <br /> Y LL 1N �4�IST12tic'1�N1_sPEciRlcl►rtoKa <br /> IdIONfTCYRING a HOl10ll51 STEM C1A OF BORI:HoLE /' MULTIALE Ca9iNes?0 YES WO WELL CA51N3 DIA: ZN <br /> EXT ION� p AIR H"MER/OR"N CASif�tG THICKNESS �,[ � TYPE OF CASINO: Q STEEL *VC G OTiiEft;,�,�_ <br /> VAPOR 11 MUD RorAMY DEPTH or 0ROvr SEAL TREMiE TYPE TO BE USED: 13 AUGERS p HOSE <br /> AIR SPAR 39 13 PUSF+POINT, GROUT SEAL PUMPED: �Yps fl No (NOTE: ltipA)A1NUM FREE-FALL DEPTH IS 301 <br /> $OIL GORING [I HAND AUGER GROLrrSPECIFICATION9: <br /> OTHER: — n OTHER _ APPRM VIORING DEPTH i 0 0 BOLTED ZRAF*IC 8OX or 0 STOVE PIPE <br /> - CONDUC CrR CASINO (If ng. .vp spedffcaaons tiarar. <br /> :aat�ttss: o�,' �o v'I�► w e� '1 ve,r <br /> 4 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 46 WQRKINO HOURS Ii,1 ADVANCE FOR ALL RECUIRED INSPECTIONS. <br /> hereby certify that I have prepared tl'11#epplicatlon and that the work will be done In ar4ardance with San JoagUln <br /> ounty O n ncsa, Iss a d ul ns,and all appfilivMble CalHorrtla State La". <br /> TlttelCemparry �'''`C- <br /> 9rwd <br /> 1n1 Na C1 w '1 l7`J!�lM Ci Date I O O <br /> DEPART _ ENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADPRE8S: <br /> FORK PLAN DATED: <br /> :pvAftn A td ar C Dale►ted Pf z 2 C? <br /> out InsPeetlan By, 77 71L1ste Ffnal lnspedbn 8Y <br /> iS�UC'tlOr1 l >� <br /> 7MMENTtf!CONDf1117ION3. <br /> =0UNTINOONLY: Alt)# PAIW <br /> Is coc" FEE tNFo AMOUNT RaMrrmnD cKEc if P• CAT6 t�st>rilrT!t3iriiVt # 61VbtG1• <br /> Lb Z CJ U ' It <br /> -5WG -WA1VFR C-57 Letter'of Author ,s o sign permit Encroachment doh_ 9/27/OD <br /> T <br /> FEB b_ cjji <br />