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L.I Ola ,_xl:fc ac IOn,- IIIc CL18-9bb-El'J'!J P. <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAI4 JOAQUIN COUNTY PU13UC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 334 E. Weber, Third Floor, Stockton,CA-, 95202 <br /> (209J468-3"9 <br /> NON-REFUNDABLE PERMIT EXPiRFS 1 YEAR FROM CArE ISSUEb J " <br /> Aoplicmivn is hemby made to San Joaqult Cwmy:M mn a pMto=nsthaLl awk' YIStBe the�.N,K d_'Gb Tys appliG nn it Tano;in Cnmoti,with <br /> San.idathim County�Ofeiabpmant Tate.Gude,9.1t 15.3 and the St"4ards of S i WI ;gan GIMI/PLOC Health Sw¢es.EmifamMnW m"Rh ONI1I. <br /> WELL LPCation .Stoort:r6m iky M1V Gasa Shee! FpV R7 R - AssessU(s <br /> _ cey ,PON z,9S366 p3heo z5Y 570_pg <br /> PROPERTY fJxwv.r N SyLF 44r f` //UC,pdyesy_ L�1�VLyn('.2v Fl LoQl2�'�PhonoII&9-5'-59`!$ <br /> c•57ConoaaorsPQJC.TRUMrzK/XC �- 23GSL+kGWA�i n�,Srax�J yP`�'zoSe;d5t2Z6Sf�l,,,,eezoq-NGS�8x72 <br /> CRnaurtant I Sh Cnnhaaor f%Q l�i W6_ST Adw.ea l BbF N. !-J�"/../t,t cly ESnJ�u� <br /> OIs Cw finales:X Y—Tawntsny T. 25. Range R• SE. sachon 30 <br /> WORK iO BE PERFORI�/EO �X.�I; � <br /> ANEW WELL!BORING(CPT. OIL RONING coPRO Jr. i-5Q(3- �(j� nUGER OTHF� 0 DESTRUCTION fcfi a type Ws ) <br /> It WPu:_ <br /> OVER.$ORE <br /> "Other. D PRESSURE GROUT <br /> COMMENTS. <br /> aFfE,C WELL WSTALL7TIOf TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING aHOLLOW STEM CIA,OF BOREHOLE MULTIPLE MULTIPLE CASINOS70 YES 040 WELL CASING DIA. <br /> M _ <br /> 0 EXTRACTION 0 AIR HAMF-PIORIVEN CA.9ING TWKNESS J/1 TYPE Or cAsm. p srFEL p PVC g mmER <br /> 0 VA" 0 muo ROTAR'• OEPTHOF GROUT SEAL WF TREMIE TYPE TO 9E USED: <br /> GAUGERS OHOSE <br /> U AIR SPARGE 0 PUSH PONT GROUT SEAL PUMPED: 0 Yea 0 No [NOTE--MAXIMUM FREE-FALL DEPTH IS 30'[ <br /> SOIL SOMNG 0 HANG AUW;'.. APPRM aOAnaC DEPTH 0 BOLTED TRAFFIC BOX do 0 STOVE PIPE <br /> 0 OTHERR CTHER_ CONOUC7OE CASMG PROPOSEOo_�l dYEs,ly sPecdralans natal: <br /> COMMENTS: Th13 1 A— �lk. C <br /> e/✓JIT/ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> M <br /> 1 fwativ nih/that I nave on paMtl thn apt srcatinn and Mal the vory xal tx done m dcCAtpA min San loaqun G"n OrdinT- Ste Latus.and Rues <br /> �d Aegudtlons of MwSan JoegVin Coutdy PbmeoVner m lio[rsM agents.kpratme MrMes the legov�nq:w CW6fy a tat in she parle,v.a„na oIntra warn <br /> br wAicn this pwnNf is lssPM.I shall ncf empbyparatlnssu0ytxt b WORftERRS'CONPAYSA'RON LaI/s of CaWorr,fa' Cethi acorn hilig or 3'0- <br /> 9"3 <br /> tonGacllng stNrycWrtifieShm tbtwng 7certd'y NN iA the patfemah,,e ofhea *AV W% funs pemMrs eaue4 fteNtampoy pergmsaru Cy,y <br /> NKJRKEAS"COMPENSA770N L of Cv fnmy.' <br /> TH PP MINT MUST CALL 48 HRS IN ADVANCE FORA L REQIARED INSPECTIONS. C, <br /> Sgnetl. <br /> SEE SITE M iN UNIT IV WORK PLAN DATED <br /> OFPAa7IYEifT USE ONLY L. <br /> AppaoaVon ActeP:etl By-. OaA lseuetl Aryl <br /> clout lntin1,,dndoom By �-tn•.n cj Dao Z�-C'C Pial lnapecLon dY- <br /> Desmscpon InsperJion By Dere ' <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY. AID* FACT <br /> I <br /> P-S�CrO—OFS� FEEINFO AMOUNTREMfREO p1ECKAVCASH RECEIVED ST ( DATE I PEAMITISERVICE REQUEST NUM HER INVOICE <br /> `.- <br /> C•37 LICENSED CON-CRAC7 OR MUST SIGN LICENSE Oc WORKERS'COMPEL SA"ITON D ARATION <br /> UNIT IV-6/23/99/s.6MPg/MI <br />