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NOU"16-2002 27.39 <br /> 9-;Z2 I la&� a ����., CPM13R I A <br /> 4707 935 5649 P.02-107 <br /> r <br /> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ����'��r! E�! <br /> ENVIRONMENTAL HFALTH DIVISION ("PHS-EHDII) <br /> 0 C T 0 3 Z002 <br /> 344 E. Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3450 ENVIRONMEfIT HEALTH <br /> NON R'I=FIft+RO RLE F!F-RIVItr EXPIRJS t YgaFt SROM DATE t$Sl1CD PERM)T/SERVICES <br /> }Dtlzatmn is hereby made I*San.Ioaq-Jon Country fat 0 Perrot ry Consrr+aCt antler 1nStatl the WOaK derstAbed Tlris appli.at�ari t,:R►a4E vl t6mplFanee wlti� <br /> an Joaquin County Developmem Tive Ctraprer 9-1115 3 ana the StandarOa of San,loaquin Couaty F u%Ac Heamm Servcas,Envmtotrntantal Hesttls 01uiswn. <br /> � / I�sSassorif�t <br /> �Z.t.ncada y e - 4c,V—'C', '•+crt••�r o Cess 51reel c.�a.,L.�c. _cdy„ S ial-k f6 l-z;--P3fCC 0�-190-06-1 <br /> ery <br /> ROPE RTYOwnkl, tIIM P1h0�, ddr�sc'JJtS lnwc� �cra.,�.�.�•SEzr�.fcl"II•. Zip`�ic'�D Fhonei� <br /> �a fir.!�.wc Addttsa � hanc�l9?�^� .SSP>a <br /> .•5T Camractor rr,s, 2570 awt Caty <br /> ;ansultant�r �.��+�ty�_:r'1D""�"��eress �/er�C,'!y o.•+ Lacµ �naneu 7a7:X33-1.?G_9 <br /> 3LS Ceapd,nates.X �Y T'evrtvsf+ap Rang@ St=MM <br /> WOPK to BE PJ'F'w0;tmg0 <br /> (� <br /> NEW WELL I L30RING(CPT,GIZOPROSE HYDROPUNCH HANDLAUmm OTHER") a OEMUCT ON(cahoass type wow) <br /> 9SCIL BORING#B!3 ff �`f _ �OVER•BORe <br /> Q wee q PRESSURE GROUT <br /> 'Othar <br /> CcMMENTS <br /> of VvEt.L CONSTRUE TtQh TYPrr EM'STRt1GTtoH SPEGt ICA'v1ONS <br /> tTCIZtN�i q MELLOW STEM 01A OF BOREHOLE2"�,MULTIPLE CASMI S-10 YES Q NO WELLCASING Ota, <br /> fI EXTRAC'nON Q AIR 4AAAMEWDRIVEN CASING THICKNESS - TYPE OIC CASING' (]STEEL Q PVC n 0TWV -P <br /> a VAPOR 0 MUD ROTARY DEM OF GROUT: 3 3 EAL TREmic-reP'E 70 im uSED, yA GNC�—SE <br /> 0 AIR$PARGE 0 Pustt PDITiT" GROUT SEAL PVMPEC�' (I Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 3011 <br /> K50It BORING 0H,1NQ AUGIER AlaPROX f3gRIrIG Dt "rH ,- J a a BOLTED'TRAFFIC BOX nr a SYOVe PIPE <br /> 0 O rHER CONDUCTOR CASING PROPOSED? (Ir YES rest apeaYCataons Here}, <br /> COMMENTS, <br /> MOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS! <br /> I raemby cmfy thet I gave oreya-ed ana that the war%wdi tie done M a=rdamm%mtt+San Jaaauut Cc)urlty Oconam*M.Stare LawZ at+C FUIe4 <br /> aric Requlataans of the Sa*+-Ioaqum Cauney "orneawner or Gwrimed agears sranatvr4 cues the foltowanS: "t cvrtfy MOM iA rha peftMa'arce 004 work <br /> Iar wja.ch rhes permit as Issmw,1 shelf Rot emptor persons stbjecr to WORYWAN S COMPENSAVON 1-*"al CW&Y6enra." CerltraCtors h1nn9 or sub1- <br /> =fWaV1111 SFgnature cen.Xss the foaa wm9t Y cemfy 1rax err We peAbomance of Me vmtV for-kicfi this petrmy LS o&WOd.I shall OA7play Persons subject to <br /> w90RKmAMS COMP&4ATI01v Laws of C oMbrme. <br /> THIP—APPLICANT MUSY CALL 48 I4RS IN ADVANCE FOR ALL REQUFRF-0 WSPEGSIC S. f <br /> � V' � l Q <br /> Signed x—BOTit! ,-� <br /> SEE SITE MAS' 1N UNIT IV 1l1lURK PIAN DATED. � ' 0 . . <br /> ( DEPARrMENT USE ONLY <br /> Appkcaton Accepted BY Lr•�r_LA�LrLr.�cY' ._..., ..Date issued rtrea— <br /> Groat Inspection By Dane Final Itr anion By Rites �- <br /> 13e^:Vuctton lg5paic4on BY Date <br /> OMMENTS l COT144TIONS` <br /> ACCQUN NG ONLY AIDC AC2 <br /> PE CODES FEE INFO AtVr01;PdT REtW rrrEt7 w.frou sT NuMBER aNtfptp$ <br /> 35a -3 S .00 Js f <br />