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06/20/2000 09:19 2094683433 <br /> 96114/20140 69:07 2094GS2433FIFTH FLOOR PACE 02 <br /> r tr ra_tAarc <br /> r.-ice ar <br /> WELL. PERMIT APPLICATION FORM U141T IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH 5ERYICES <br /> ENVIRONMENTAL HEALTH DrVISION (PHS-EMD <br /> 301E.Weber, Third Floor Stockton, CA., 95202 <br /> ... . (209) 468-3449 <br /> SM K&2FUf! t. a s FROM 0 IRL103 <br /> APPiiclon Is hcraby mase to San Joaquin County bra permit b construct and/or install Ole r,mR 4astxibed. This appilcation IS made In compliance with San <br /> In County 0aveicomeru�-nue.Chapter_4-!'i 153/and-the Standards of San Joaquin County Public.] &Wthth�SwAces„Envllcnmaniai HeaM OivWorr. <br /> Cross St/ret} ty .t��`,�f//i%1 �lF��_ParaeltF cp <br /> 11PERTY <br /> Owner t rrt:� Addr+ess_I <br /> CCM1�SGtpr Alts ' I ttanefaa <br /> CansWtaa[1 Sub Canrracinr Add,.Oss OP LGVYJ,r/ G" fr1J� y kwnel �� <br /> .� .Y ,7avrnstup-- 10lovRange �L Sectio /�4Ca.drdiravew <br /> R TO BE 9PPOA IED: O <br /> }�Iew WELL r BORING(CPT PEOPR091,HYOROP y Q- HANK, U R;OTNElt') j1 Dt,:MUCTION(chaose type be)ow} <br /> ■ (SOIL BORING W a OYER-60RE <br /> 12 WELL A 0 PF:FSSUIkE GROUT <br /> ' Sher. <br /> MMENTS: <br /> i lP WELL INStALUITtQN Pir _CoNSYRUC tV:�SPEGtFfCATIOAIS <br /> GRING 12 HOLLOW STEM OLA.01~SCREHOLE-_MULMPLE CAS;NGS?Q YBS I)NQ WELL CASING pia <br /> cnaN n Ail KAMMERlt;3PiIVEN CASING TMCI0.Cs5_T P;_OF CASING: 0 s"T7M 11 PVC 00T3401_____" <br /> fQfL <br /> POR Q MUD ROTARY DEPTH OF C TOUT SEAL._TAME TYPE To Et:kj3ED. 1}AUGERS 0HOSE <br /> Q PUSH POINT GROUT'SEAL.PUMPED: p Yes U No f NOTE. MAXIMUM FREE•FALL DEPTH 1S 30'}BORING q DANA AUGER APPROK BORING DEPTH 11 BOLTED TRAFFIC AOX or 0 STOVS P{PE <br /> a OTHrm. a OT14ER. CONOUCTOR CASING PROPOSED' (if YES,list syedfications here): <br /> MMENTS: <br /> NOTE. OFFSITE BORINGS.REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> erQby Wrdty slat t hew prepared this eppilcsbon anb trial the work will be done In eommiiince with San Joaquin County Oidnarrmc,Siete L,-ma,and Rawles <br /> d RegW2ticni aE the San Joaquin County" Iiomwwrier or Iicansed agents signature caardAes Itla WaMng:'Y eefl.Yy thatlir the per mxi/ve of Hae Work <br /> r Wftieh Etats permlif is isslavd.f shag not employ pegsorr4 sYbjeet to WORICEAV COMPEWSA77CW Laws of Calif amia;' O0ntM=r s tprtng er Sub- <br /> conlractlIT9 siynawra cediees the fa tiowtng:"l w4fy that in the performance of ft w i*forwfth Nis pamff is Issued.I shah employpersoaa subject m <br /> ir <br /> 0<9AS'CCMJ�'JrNSATfON laws of Caftmia.' <br /> T N!T IV INSPECTOR 48 W8RK1w HRS IN ADVANCE FOR ALL REQUIRE INSPECTIONS <br /> Signed x TIZJeII`:,r,aarly t.�� r <br /> 'rfnt Name_ � �'LL�JA�i00 <br /> d or SAPSITE FILE ADDRESSIWORK PLAN DAT -0 o 40o sZZ0 <br /> [)EPMW.._ air <br /> pli0adar, ta:d icy Data Issued_ L -_A0 <br /> aau;In"tion BY Data Finalapedion e , <br /> Csftaon Invectiean Bl DBI <br /> il3iit1Elt s/calmmorn: <br /> AccoumrNa ONLY., ADO <br /> PSCODES REE IKPO AMOUNTRBMtrIBD CHECKV RECO Ey DATE PERMIT 1,99RVICS REQUEBT0 INVOICE <br /> C-57 Exp. WC.1wdlver, C-57 Letter,of AuVriorixation to sign permit_ "..._Eh4roachmmt doc(s), 5/17/00 <br />