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11/20/2000 16:48 19166385611 GA5UAllt 1.)K.I.LL1f\lb - <br /> <br />1-*Alat 104 <br /> <br />! 92 /I OR VITAL <br />WELL PERMIT APPUCATION FORM <br />SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Websr, Third Floor, Stoeklon, CA, 95202 <br />(209) 488-3449 <br />NO/I-REP UN DAMIAPIERMIT EXPIRES 1111AR FROM DATE tutu <br />Applicator Hi Ravey made b Sac Joaquin Co'* few • pewrit le oonatn/ol angina( Instaill ha work thecoribad. TrIu applaud= la wad In adllaradwall INA <br />C•ltirlY DIFfeloPfflent TON, Chapter 11-1110.3 WV the Ellardavas of San .113•9•In Oa" Pubic filealth Santee, Erreormentel <br />ieu Loon 419 o eArn6ei simst Lou 15f,Mity <br />AINNI111061 <br />PROPenrr ONTIOr C ?-0011,1 - . 4Nt y bcrsi-texia mk,12LytionesD 'WO- /Co 75— <br />C4117 Conlractor raillad,ODILLItteSEY <br />Consular/ / Contractor MT C..4e. Addiva• (2_ Uo/ <br />Coartilnatat X Town** Rano Eadion <br />igtVIELL./ ESCRINO ( CPT, 0C-OPROISE, KYDOOPUNON, HNC-AUGER *Then <br />IAMEDAMUIL <br />011. SCRAG IP <br />ELL inkAr71- <br />srrE <br />MIT/GATION <br />UNIT IV <br />Vidor <br />COMMENTS: <br />Orme <br />I) DESTRUCTION (choose type bear) <br />O OVERSONE <br />a PRESSURE GROUT <br />TYPE OF WV,, filITALLATIOrt TYPX <br /> <br />WilONITORING -A401.1.0W STEN <br />ti EXTRACTION aAACHAMMWVONVEN <br />El VAPOR • a MUD ROTARY <br /> <br />AlR WAAGE a PUSH POINT <br />II SOIL BORING HAND AUGER <br />3 CITHER:_a OTHER <br />'7 II <br />DIA. OF BORN 'WIMPLE ciesreiern u ris let4o WY-U. CASING Pk 4-• <br />CASING neooattes TyPE pF C.A.811411:k D uOTHISM____ <br />germ or artOUT um, 2 TRW* TYPE TO SI ISl , IAUIU a NOSE <br />OADVT SEAL PUMPOD: a Yes V4o (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 <br />GROUT EVIEGFICATIONIIL <br />APPRQX WRING DIEPTH caii*P4 Viocreto TRAFFIC sok v usrovt PIPE <br />caloucToR GANN* PRoFceerrt ND (VVU, Ile 40.01110•Klell <br />comeeENTII• <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br />CALL THE UNIT IV INSPECTOR ea WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />I I h prepared this applicatIon and that the work will be done In accordance with San Joaquin <br />s and Regulations, end ell applicable California Stale Lew.. <br />ntierampeer Of r -tyr . C.-as:cc( di fir, I /1.7y <br />C7EPARTMEKT USE ONLY p.m II‘P1)° ° 1/ 45\— <br />,..C.ArrIele-V 0 Gel peztx" <br />WORK PLAN DATED: • r(Af44 <br />I hereby certify <br />County Ordl <br />!Signed II <br />Ivint Nam <br />WE MAP IN UNIT IV FILE, ADDRESS: I <br /> <br />Dele isausta 2-1 '-C)C4 <br /> Final Inspect= Ely 9f, <br /> <br />4pplicabon Aocalipard <br />3rout Inspaclion Sy <br />)entructiori Inepedian <br /> <br />Al. <br /> <br />• <br />Acompowalowr AEW I FAG* <br />PE CODES f ER INFO AMOUNT REMITTED CHECK i NEC-0 BY CAT! .--rsk_Sir-xiservtesitkiniers-, Ames <br />1- (co CsagLa24t.(9T- <br />C-57 <br /> C C-57 Lerter of AuThodzatlon to .i19n perm