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JUL-27-1999 11-13 <br />P.01 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEAL11H DIVISION (PHS -1 J U L 2 81999 <br />304 E. Weber, Third Floor, Stockton, CA., 96202 ENVIRONMENTAL I•-iEALTH <br />(2091468-U49 PERMIT / SERVICES <br />Nb g;F;lunA9t r- POWILIKXP'RES 1 YEAR FROST» IERSUED <br />ApPligtipn is hereby rAgde to Son Joel In CouRty, for * pefnd pD ooMtrLGt and W ingatt #0 Werk deaGA appllcaaon matte In compllence with <br />Puolk Hestth SertiiOes. Environmenor Mealm Division, <br />$en •1oe4� (qumy Dm,�pn,ent TOe, CMDI@r 8-t t 16.3 and the 9tander6s of Sin JaaQuln County Assessors <br />$� N 6v r NerTI 8 a )e rOr✓ <br />4ALA�`CImStrom 'b <br />vvft L I.ocalion� LVP4$ ll A.)dT*J <br />PItpPERri owner GE G A .'�i�AGrio� 1^adr®as, iraoc- C��ydPnen�4zvo <br />C-67 Conoto* n dMs <br />tJ><cG OA �2a✓l. 9Tr/y1-►•'r' DhonePS/�'�y'�s <br />Cor►sukant / S+Ib Contractor <br />y AdOrOia �'e rc -I ° a y 0/9KL��SLiC1h <br />GIs Ceoonam. X Y� <br />. Township Range Section <br />WOM TO fie t+ o <br />0 pE5TRU0TION (choose type below) <br />NEW WELL 1 BORING (CPT, GEOD'ROBE. HYDROPUNCH. HANG -AUGER, OTHBR') 0 OVER-80Rrx <br />.SOIL BOi41HGi,f t 2 p PRESSURE GROUT <br />12 WELL a <br />Ml iNgIrA 'MN vF SORrxa • -__- - y NO WrsLL CASINO OtA: <br />��� STEM Dl/►. OP 0RE1f0 " MULTIPLE CASINGS? 0 ES l <br />MONITORINGTYPE OF CASING'. 0 STEEL Q PVC 0 OTHER; <br />0 EXTRACTION 11/UR NAMMERIDRNEN CAS1Na TwCKNeSS�r <br />0 VAPOR p MUD ROTARY DI -PTH OF GROUT SEA,.,_ (NOTE: IIMXIII�UM FREE -FALL DEPTH Sr30 ) <br />n AIR SPARGE it PUSH DOINT GROUTSfiAt PUMPED: Yes Q <br />APP}tOX. 90RING DEPTM • oft 30 ? o elOLTED TRAFFIC BOX or 0 STOVE PIPE <br />OR <br />0 &OIL BING 0 HAND AUGER <br />0 oTMeR:,�O OTHE <br />CONDUCTOR CA91N6 PROPOSIaD?_ — (d y", specif�caoona here): <br />COMerf1T1TS: <br />NOTE: OFFSITE 13ORINGS REQUIRE ACCESS OR ENCROAUHmr`1v I rl^t"' Rules11,00 _ <br />I hereby OGnify That I niw Oral 4 this appl"Llon and chat the work well be d=Meluri C9401,es the foguow"g � °°�f That in fhe Performance or the work <br />and Regura,Uons Of the San Jottl Covely. HvrneW~ Or Ilpen9ed � gConUacWs <br />for wAiN this pe►rwf is Issued, t shoo not en+pby peraa+s cubJecr ro wbRKf3t5, CONPPJJSATIOM 'Ila js�d, I sbru emWoY persons nwe/ter fo <br />pontraerinp synature oertfts the rcUowinp, 'i o�y that fn rile pr rformamm orthe wont ftp► wfrkh MIS Aerm <br />WORKERS' COMPENSATION LSWC Of CmWfOn a.' <br />THE q PLICA MUST CALL 48 HRS IN ADVANCE FOR ALL REQUIRED INSPECTION <br />Title <br />S,gntd k <br />SEE -SIT-E•.-J"R-UNIT 4V WORK-PLANv DATED <br />DEPARTMENT tseO <br />• Date Issued �' �'4 � <br />pppliratlon Ac00pted `y Dasa cs Fi#*l InWcoon Sy Date <br />raraut IBspeclion By Oats 3 <br />Destruction lnspect'on Sy <br />COMMENTS I CONDITIONS: <br />AGDOUNTING ONLY: AIDS <br />PfiCODES FEE INFO AMOUNTfEW"ED CHECKNCASH <br />�oI x.00 S ,00 3 S <br />C0NTXll0I t MUST SYGN ij <br />�@,yXt PV - q.3l99 /sign bkpg/MI <br />yt iCEIVED SY I DATt' <br />puw"it IINMCE <br />DECLAF A-n0N <br />99*z P. 02 <br />-7 <br />F,/" ab?6 66b 5l 66-/_Z-Tnf !Z0E0 EL6 SM `• •Dui `bUT;Sa1 V bUTTTtup HaJD :/(g ;uaS <br />