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96/16/2903 PB;02 2994683433 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (END) <br />304 E. Weber, Third Floor, Stt; ektam, CA., 95202 <br />(209) 4683449 <br />PAsE as <br />SITE <br />MITIGATION <br />UNIT Ill <br />F 11" <br />1ppNim it n Is hmw*I2 r made m San �aaa�4t GourllyR+r a pesrri l Ge aarrsav ahNerius4lt the MbrR TS16 aDplit2ffion is encode In compnmbv,wdh Bart <br />lo"Oh County pco„relopmgnK.�ld_e, C11aoffir 8.1115.3 npd 1I e.seundarda of San i—T in County EmAroruflentsl HMM 0"ItmeM <br />KLLLboeatlon'Et G�csl.cro__ed �_ a�.I oe o r�c� I zip 95�.c,� as oti`3�_ <br />NROPOATYownK5 t� `���� gd4less 3 �iV�ttitti�e.� clklr 5��+ n ?lad? `�he�,�►_.� <br />C-97 <br />013 Cegrylinalt�: x Y 7omruhlp Ran�� al <br />rlttic Ye r v etr_ <br />it NE'W WELL/ BORING (CPT, GrzOPROSE, HYDROPUNCH, HAND,AUGER, O'MER) I] DESTRUCTION Iopwc beldv) <br />Ia SOIL aaRMS IR i] OVER-WRL DIAMETER„ ) <br />�KWFLLrMNL�/ — 13 "Es1$Ua» MOW <br />u•0aver IG TBPCOIRICAnONS <br />COMMENTS: tea. Lt WWL'P!'.,. A4ck*4,-,w. <br />1[m OF =&& INSYA4L,A'rl s Me C014MM TIDN SPErFMATIM" I ) <br />>KNONITORING WOLLCPW 91'HFA D{A_ OF HCRENOLE�U y 11 <br />UUMIkim CASINOS Q MULTI -LL -VEL WELL CASING Duh: . <br />Ii 15MA,C7I0144 0 AIR HAMM15RIDRIVEN CASING THICKNESS scl� TYPE OF CASING; a STr-M XPNC 0 OTHER: <br />0 VAPOR 9 MUD ROTARY 088TH OF G GOVT SEAL n TREMA- TYPE TO AF U99131 p AU6ERB 0 HOSE <br />n AIR BPARCINJ OZONE 0 PUSH POINT IOP or CPT) GROUT WEAL FWPIED; Q Yes *No Mom MAMMUM FREE -FALL DEPTH is 30") <br />0 SOIL, BORING 0 WWDAuGER BROW SPEOIPICAMONs- (Q Cor r <br />Ij OTHF_R: It OTHER APPfROJC wRIMG l) p OmTED'fIZApmc BOX -w 0 smvr. PIPE <br />0ON%JCT0R CASING PROPOSED Of 'MR, krt spedfir *bons in mmmsrtt sedan) <br />NOTE: OFFSffE BORINGS <br />ASC <br />AGREEMENT OR ENCROACHMENT PERMITS. <br />NOTICE REQUIRID FOR INSPECTIONS. <br />I hereby celtft that I have prepared this application and that the work will be dorte in accordance with San -Joaquin <br />County Or laances, Rales and Rag�1taUmns, and all a0plleable Califemfa State Lawn. <br />Signed x Cl( Tltlelr�onlpBRy L� ii2`i~ flG f4 /4 I�I + Lr_ I r. C� �� C-, <br />r �J <br />Pont NnmiR Dobe <br />SITE, MAP IN UNR' IV FILE, <br />WORK PLAN DATED: <br />lr <br />appneagan Aea&ptAd ey (� �1�M0 0l h -- �D Issued Lf <br />Q=t tmcpedim By <br />Deslm0krn In cn 0y Date <br />COMMNNTS t COMDITIONEL <br />aCCAWNTING ONLT: AID* PAC# <br />pE cOD�C Ff E lMFCi AbIOItWT REInTW f CKCKi RSC•D RY I MTF! Y U6 T# INVOKE <br />5'0 <br />C^5l,�_ WG,_.1i A.TVER— <br />zoom <br />00 1 002]wzz- <br />0035 <br />Letter- of AuThalriZotyan to sign perhllt_ n 0 9130/02 <br />a <br />San 0062849 9T6 TkT RT:bT Milt C0/WO/TT <br />Z00ln S811 006Z6L9 916 XVJ OZ:9T 3fli EO/h0/TT <br />