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oAp r , A. 2000 10 : 35PM'AX 913 777 4101 V titi' DRILLING IN'C No - 1124 P - 2/2>o2 <br /> Aor . y. 2u00a10.11PIM1 TO ;No•I123 P 2/2 <br /> �> WELL PERMIT APPLICATION FORM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PIIS-EHD) <br /> n 304 E.Wabur, Third FLoor, Stockton, CA., 95202 <br /> (209) 40-3449 <br /> o NOr}•R,E N a PCRIOT EXPIRES 1 TF. OAlE ISSUED <br /> AppflcaUon hertGY MadC 10$St1 JoaCukn Courtly t a pefmn k r:Onatruct arWw inatan Ms heft rDGSUfhcq. ODpliCta tion C,made rAmfll,>f rt<t WKS. <br /> Baa JofGwO GO r+W OevelnpMePt Tule.Cnavter 9.111 S.3 and the 9und2r4s o!e-#A JoaRvin r avnly PubkL MaatCt salvtce6,Enr,IaQnnSMtfIUlt cafth 00419ian <br /> W � <br /> EtLocali0n$y^l� E c GroSSStrGel w,fFRGe ST Gly 416-7NR.�P Py �PBrcel+� � <br /> PROPERTY ownert4V'_71'leill F Aadrsss /��a a.rrcto.I PIu R� .Ciry ra,�reKa ZfpQ �UPnartian l <br /> G51 Gbnlraum +w Dt< APntass (�o- 13oX �//(a C _-'ZIv CiQ7.id90 Ppan■e 9 777 y/tm <br /> con+�ItA^tts„ec«,Ir.ete' Ce.•..aye Anereaa��J"X�fr'Ic�e�l�'f_Ciry��K1a-tick' Pnene�_,ta��3y.«g <br /> _ Ta.ns>itp L.0 Rttngc� E 3etylan 3•.3 <br /> OIS Cpara;ngaL'X, - Y--- — <br /> WORK TO QrA KRFORMEE) <br /> Q NF-W WdLL r DORtKG 1 CPT,0P.0PROBE,NYOAMPUNGH.HAND-AUGER.0TXFA') 0 DE3TRLXTI�O rt e�POddt We be1o"t <br /> )j SOIL H0RtNG10 Q PRESSURIZ GROUT <br /> cy p tIJELL <br /> ,other! d ��.�CC roo rC ' .ti I/1 I4 Ml4.Cl-� 0G.S f.� L !l/�r <br /> CQIAMENT6: 7 Av'� /r��MC at rr Z.5 r r(/A'� /�" 6.e ''a G <br /> TYPE of wEu t s N PE ON TRUCTION SPECtf1CATt <br /> Q MONITORING (j HOLLOW STEM out 00 VOIRENOLE MULTIPLE GSINOS7 13 YES p NO WELL Cl�SING 1JtA: <br /> 13 E7t7RACTION 0 AIR WAMMEp_roH v4N CASING THICKNESS T`rpE Of CASING, G STEei Q PVC p OTHER: <br /> D VAPOR 0 MVO ROTARY DEPTN Qf GROUT SFAL TREMIE TYPE TO at USEt)' D AVOERS CH05E <br /> 0 AIR SPARUt D PU501 POINT GRQVT SCAL PUWr%D. 0 Yaz Q Nv (NoTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL 80RtNG AMAND AUGER APPROX,CORING SEPTIA d$OLTEO TRAMC BOX or 0 STOVE PIPE <br /> p OTHeR. 0 OTHER _ CONDUCTOR CASING PROPOSE01!0 {If YES,ttzt srtectifieai ma t+o'e). <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> 1 ArtrOy cvtuy Shat I hive CraGaftc3 thlj.npofrbllan and,that Ins nark—4144 Done In eocardanoe wRit an JaMmm County drSiAzAC4#,SlAtr l;ua and Rutcs <br /> ane Re9�Ivbns o1 ttu San Joypuin Couper ^�or lkrroc0 agenC�srg^aiw.ceNllars Ino Iol4.t'�y:'r NNIy(hal rn Lti1 plrrfw+rra^�ar rh.v.arY n/` <br /> fa wnfdh 04SP&MIl is lu'Jee,I shall aloe emvlaY Pclsons cvQfccr to WORKERS'CO(OPUNSArrON Laws of hRnp w w�- <br /> CONrttcivv Lva4ke Ct"I its tRc Ioba"inp;'I Cetly anal to the Pa rforrna�cc or aIle.nrk/O wduCrr rt rx(1dnYt+l!s l Ia,I�l1aH a*p'ey pvrzwta>tta0la t <br /> WOR)cFRs-c0MPEN3A770N Laws of C8l MIR-_ <br /> CALL THEUNIT IV INSPECTOR AS WORKING HR5 IN ADVANCE FOR ALL REQUIRED INSPECTIONS- <br /> N V & W Drilling, Inc, <br /> 5sewo x 7alr�Compa*y <br /> PI1r1Nartle Robert E Vickery D.te 4/4/00 <br /> SEF �SI`i ^�MAPsLiN; ItNIT>lV-�fII�ORtC PLAN'?DA, a= .': ` <br /> e MPA-RIWNT WE ONLY, / O <br /> A"katbe Aocaoted By / '( 011e towed ( 0 D Area S� N) <br /> Grout Inspetl an gY <br /> Date Flrtial lnspQCtion Br OaWr� <br /> occln,rsen Irtfp4c110n B Data <br /> COMMENTS I CONDITIONS' <br /> ACCQWffING ONLY: A41)0 <br /> PG COOEs FEE INFO AMOUNT R£tivrrEo CMCCK K REG•O AT OATe RfAA"T I SERvier wngU£ST a JNVO1Cf <br /> fit- //?7 <br /> I/W2o00 <br /> 04/04/2000 TL'E 11:16 ['rX/kX No 53281 91002 <br />