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SEP-19-2000 15:51 FROh— 'RECISION SAMPLING TO 12094683433 P.02 <br /> WELL PERMIT" APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MGATION <br /> ENVIRONMEN'TAi_HEALTH DIMSION (PHS-EHO) UNff 1V <br /> 304 E.Web", Third Floor, Stockton, CA., 95202 <br /> (209)468-3"9 <br /> 9CM4MFUNDAM.ra MRM EXPIRES'I V-aaE& <br /> AppfleaUon is hereby moat to San Joaquin County for a pern*to consfiuet and/or Irt W Me vvwt described_ This aWc ation is rrrad a in compl ante►lith si;n <br /> Joaquin County Develolmw*Trift,Chapter 9-11152 and the Stb+tdardc aE n JoagUr County Public Health Serwleos,Environmental Hodth division. <br /> tlrr=T f_ U • � � 5 str> t a8 <br /> PROPERTY Owner �Q �DL���.y�� City !PhoRaF <br /> C57 C**v1dor e t '�rrorr Address N00 Cihr <br /> ConstmlrAtlSUbCarr�ad �t+,ddrrsB �Y tit Phone# <br /> CIS Coordinates:X Y Town--NP Ran9e__._......_, Svalon <br /> WORK 70 BE EMEQ <br /> Q NE=W W ELL 1 BORING(G�E,HYDROPLiNC MAPF!?,0.JGE .QTHERh U DESTRUCTION(choose type below) <br /> JUiL f�QlZt+fC P,. i •I�p <br /> 'D OVER SORE <br /> FJ.4 S, 11 PREMURE GETOUT <br /> GROUT SPECIFICATION <br /> COMMENTS: <br /> I=QF WELL INSTA LATION 71rPE MSTRY-CTaON SPE <br /> 0 MOMMOHNG Q HOU-0W STEM DUL OF BORE-H0LE_?�MULTfPtF CASINOS?D YES ONO WELL CASING D&k _____„ <br /> D EXTRACTION D AIR HAMMERAWVEN 0AS;r4GTH1CME3S TYPE OF C.A,SN•1G: 11 STEEL 11 PVC 0 OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GRCLrr SEAL TRr=Mr=TYPE TD BE USED: O AUGERS []HOSE <br /> (I AIR SPARGE PUSH POINT GROUT SEAL PUMPED- D Yes D No (NC3'FE MAXIMUM FREE-FALL DEJ' rH is 30 <br /> D SOL BORING Q HAND AUGER GROUT SPECfFECATION <br /> O OTHER: Q OTHER APPROX.BORING DEPTI.1__. i_0 BOLTED TRAFFIC BOX or Q 3TOV. E PIPE <br /> CONDUO-P CASWG PROPOSED? {if YES,list spoc3ficatians here)_- <br /> NOTE: OFFSITE 86RINGS REQUIRE ACCESS OR ENCROAC&ENT PERMITS �4>� <br /> 1 hereby certify that t have prepared this apprWatlon and that the work will be done In acc* dance With San Joaquin <br /> County Ordinances,State Lajas,and Rvles and Regulations of the San Joaquin County. <br /> L THE UNIT IV INSPECTOR 48 WORMNG HOURS IN ADVANCE <br /> FOR ALL REQUIRED MPECTIONS <br /> slgeed \ ( �� 1.1tZo /ev,`Y TitkX mpany P � !/t�te✓1� /`�<. '�.SIr c <br /> Print >Z9 Dat® I ^T <br /> SITE I'1dIAP IN UNIT I [LE ADDRESS)WORK PIAN DATED <br /> Of DEPARTMENT USE ONLY <br /> /+F►Po Accepead SY Oahe Issues{ <br /> ,t Inxpeetltm 8"f —Data. . -- Fnal lnspe.Slam By �� — <br /> DastucAon Irmpedlon.py Oahe <br /> C MIME"I CONWnONS: AA <br /> ACCOUNTING ONLY. A)D# <br /> PE CODES FEE INFO AMmoUNT REmnTED CHECKa LRE-C'DY DATE t§i <br /> /SERVICE R�Lftc T BL04v()1a <br /> F <br /> Z <br /> C-57,� WCIWAIV�R C.-57 Letter of Authorization to sign perrgil`i=rtcroacFtrnEni ttac _ 9/12100 <br /> ze 3Jad ;L nn-e J U I .[T J ------- ... _ _ <br /> TOTAL P.02 <br />