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Aug -20-99 0E3:43A VIRONEX, INC_ <br />"W-81-01 LIS! 0. E l H17 <br />5102660963 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS -END) <br />304 E. Wert Third Floor. Stockton, CA., 93202 <br />(208) 468-3449 <br />P.03 <br />P. 0? <br />ORIGINAL <br />UNIT IV <br />hgtipr, LiQN•REFUNOA0IF EXp1p Z VE" t7tR7M DATE Ssu <br />ht,int y 3wvei to San Joaptpn (panty k+r 8 permit to cvnehuCt and/or mflsr the wvth deta,bed AL sppl ul on m rnada In cumPttBnce xAh <br />&.n Josgwn County o.,ebpnK tl Tdtc, c +voter ¢ 1113.E ani? the SlarWords of San Joaquin Coa PUnk <br />my Health ServIL88, EnvitvnrnerRaf Miilt� Dmeion <br />WILL tsvrf9onQ�� Corse street Suon6 St. Ci Aaceisvrs <br />PROPERTY Owvter�gf(t{ S��Q R Gty *J4 Q [y <br />� Zdl <br />c•tsrco^Rt.�...,tc?n_LY. �„fAdve 3x,Z S�. C.rytMMIWU[t�PllrotLTjY��prorrNStc Crll.(� <br />Coetsuleent+6t.b Cott:rauvr �,raisa7 F Ili O <br />T� tY� ( R[�Ucs - -PhonN s <br />t,iS Cootd nstve X --' Y ..... Tognynrp _ _ Ren4e section. <br />Q "kW WLLL I SORIfvG ( CPT. CaFOPR08E. HYDRO M(;M HANL"WISGR, OTHER-) Q DESTRUCTION (chaote type belvw) <br />BORo ys+�go <br />+Na r . 5 - \` p ov> RJBORe <br />•Other: iii V. PRPSAURE GROUT <br />COMMENTS- <br />--- _- •nry�,.vn �� fyynatftyG P -- <br />U MONITORING 0 HOLI (YIN STEM Dlll OF BOREHOLE <br />3`t � MULTrr� CA61NGS? O YES 0 NO WELD Cwh31Na tNR _ <br />U EXTRACTION Q AIR HAMME"RIVEN CASING THK:KNEe5 TYPE: OF CASING: Q STEtL () PVC Q OTML-R <br />Q VAvpR 0 MIUD gOTARY DEPTH OF GROUT SEAL TREIAIE TYPE TO 8f USED p AUGERS *Ost: <br />o AIR SPARGE X'valf MINT GROUT SEAL PUMPPD. U Yta Q ko (NOTE: MAXIMUM FRtE-FALL OEPTIi IS 301) <br />Q SO& sopme /lla HAND AUGER APPP=. Soma DEFT" n TED 7AAFFtC BOX or d STOVE. PfPE <br />OTHER CONDUCTOR CdLSING PROPUStU7 (if YES. 1181 SpecitvehpiS honk`) <br />COMM MT& <br />,W NOTE, OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />; 'Uraby Cgnity thst l have Pnt Imd Na app attpn and that the wort well be dont in ecao+dsnte with San Jvegvin County Ordinance,,. State Laws. and Rules <br />anh Regu+sows or rna San Jpagaln Cowtty. Hoe'KOwfiet M KUn+IAp agents srgnetu>• aerti/les the toff 9 <br />fpr wA+clr wa pamrlt k uswd 11haN not"'k�ir9 rAly stat !n tAe parlbrrrwrn • of rM rvodl <br />errWpY vfsaer *t b WOAKER>< C0WEN3A flON taws Of C0MMIs.' Gontraaoet bi irg or tub- <br />wnir.ctk g dy_�stun•vrnflcs trio tt%lovrirra: r ow"y "w'" fho "wrf0— nci d IAa worlr br wh CA Mra POW rs rood. I shog emPoy persons wt/tc? w <br />WORKERS' COM ENSr1 r.01V Laws of C aiaWrft - <br />S9nwa_____ <br />r� r <br />SEE SITE MA IN UNIT IV WORK PLAN DATED.- <br />MpmtTmf!pfT USE ONLY -- — <br />AMication Acceptod By <br />Grout InaDactwn BY _Osie Final Inspatxlon SI Dale <br />Dsattucwn Inspcctvn BY _ n. — <br />CMUMNTE I CONDITION. <br />AGCOUNTING ONLY. I Alp* <br />PE CODES fEE INFO yAOt1N7 RJ IMfTTEO CFTrCK r Ittt 'D BY DATE <br />D! <br />UNIT Iv <br />INVOICE <br />7 ,I <br />l.u-IYf 4 l -L JtM : j r G=C I —iii .. R <br />