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JRN 02 2002 12: 41 P?FGG DRILLING 9253W02 p. 2 , <br /> o�InllLnnl 11:36 2@3==y =2225i <br /> `kms �MO[)E5TC? ATC I PAGE 02 � j <br /> - A ti10` <br /> WELL PERMIT APPLICATION FORM <br /> SIT <br /> SAN JQAGIVIN COUNTY PUBLIC HEALTH SERYICES MITL <br /> Hs <br /> ( -eHo� <br /> N <br /> ENVIRONMENTAL HEALTH DIVISION P UNI <br /> 3D4 E.Wsber,Third Floor, StQ`010n, CA.. 95202 Fly <br /> . y' : (209)468-344 9 //l�Y� <br /> A;jNI;sYOn is h h ` ` <br /> Jnspuh Cavnty De+vefa de Sart Josqutn Count'for a perrrdt fa ansbuct enWar InehNl Vm worts deecAbs4l. Thio eppa1403n Is mage in mMOIFCe W}j' Sar. <br /> pmenr Tg'1e1.Chapter y f!1&e,and the Sienderda of Sari Jm pdn County PUNC Fleetth Ser+Aps,Eft rdnmenjol Help,Oideiea. <br /> crw,sar,et t t C' , s#at r0��reaw i <br /> Ptaaptat;Trowner t 4 <br /> car conrtectar it Addrep fg A4_ cA4_ cry aAv.�z►A!�! <br /> _s�61Cse�Pn 3 � SY�a <br /> Conewtom I Sub Cantmetar a'TL ""10L 1+1 AaOrasra. l k� l a+�Ph.1.:,.�dIp <br /> CW B. LkCO3__6_.Phanetl 'CIA-Z t- I <br /> am cow6ha w.Xy <br /> Tawnshiy Renge <br /> Q RM W LLI SORtNoMl COPT.GEOPROSE,HYDROPUNCH.KA DER,OrNER') �ESTRUCTIOt�IrJrocee gree be ) <br /> SOIL 9oRINp e 91?) <br /> 'Ocher: �irLL r # a PREA URG K <br /> COi�{bltlVTS; <br /> Gnwl NEAT <br /> Q PI2iSSURG Cidt!)l3T <br /> P CONSIAgeym 3mccigmammZrI <br /> CMP <br /> LLOW ST04 omofzoRammr, ItWtTIPLE CASINGS?p YES kNO WELL CASING DIA:—_(IVAPOR QAIRHAMIAER/DRIV N CA"40TIMICKNESS rMEOFCA ING: OMEL PVC QOTHER- <br /> Q MUD ROTARY gPTH CF aROUT SteAL j�L__TREM E T4'PE TO BE USID: �AUOCRS p Hose <br /> II AIR SPARGE la K&H POINT GRCUT SE'.AL PUMPED: bless 'a No (NOTE:MAXIMUM FREE-FALL DEPTH 13 30') <br /> DSOIL BORING Q NANO AUGIR GROUT SpECIFICATt", A-d" <br /> 4Tk : TkER APPROX BORING DEPTH S ID BOLTED TRAFFIC 60x or a$TCv�P1PE <br /> CONDUMR CASING PIROPi7 l (if 1►E6.iNle_0edieatlane meta} <br /> 'COAIIMIEHt+: soft <br /> j <br /> IF <br /> Ida J% <br /> NOTE: OFFSITE 80RINGS REQUIRE ACCESS OR r:NCROACHMFKT PERMITS. <br /> CALL THE UNrr iv INSPECTOR s1!WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby cartity 11hat I hoes prepared this application and that 11he work will be done in accordance,with San Jdaquln <br /> County Ordinances,R_u/tes a_ � <br /> n�RaSulmOons,and Ili ePP11"W 9 California Stag Laws. <br /> PAM Name ,-� I&A ! G-, <br /> DEPAATMEN <br /> T USE LY <br /> ' / <br /> SITE MAP IN UNIT tY FILE.ADDRtSs: _ /�(/6 K/ ��:' <br /> WORKPLAN DATED: Q —DI <br /> APpgoftn Acaeplad EY Dow Issuers -Q Z... ,yp Q O <br /> -tet Grout hapscWm gy Dsr rrinal hulpefxiort ay <br /> 00souckm Ile pea• <br /> eata�lrts rcvNnrrlorEa NOW <br /> ACCOUNTING W&y: AM JVACA4 <br /> PE CODES FE!INFO AMOVIIT REmf"gv CHlIGK/ RECD EY DATE ►l RMir!atA�Rt:GUEBTi i811VCICB <br /> • 2 <br /> C-37 WZ -WAVER C-57 Letter of Authorizatlon to S,gn parntitEncroo hMent dos 9/27/00 <br /> 4le—� <br />