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tm z <br /> DRIGWAL <br /> 07/7l/9A SPED 11:56 FAX 010 663 6350 GEOBATRiX OAKLAND <br /> - r <br /> WELL PERMIT APPLICATION FO <br /> SAN JOAQUIN COUNTY P.UBUC HEALTH SER S D�r <br /> ENVIRONMENTAL HEALTH DIVISION A., 95202 <br /> 304 E. Weber, Third Floor, Stocktoae CA.,85202 <br /> (2091468-3"9 <br /> rnn'eE00ASLE LWTA ffl In <br /> 1 TSR FllolA_OATE KSUFA <br /> Application a n.mltY MOM to San Jaequa+County for a punk Is c,"a W sntlJpr hrlM trw wo*deacnoad. This apphcalbn is made In tanlpgono*" <br /> San Joaquin COUM OavakprMm TMa,Chapter 2-1115.3 and the 819ndenta of San JcagON County Pubec HeaNO SWICSS' antalaHas"06is O <br /> Assess <br /> WELL LocatlOa 2ASS !De tYse-f s�rA-_cbaa sn+.c�Q1n• � LP.Y�e3/ �%�Panar ?J5B�3 Z <br /> PROPERTY owner F--,A C'fY;au�e(� Addleaalj r' IDfin ckYSG �ap��JJ¢Phenw2o4- Z�71C1� <br /> C47Conwactar&'dO iilPwn JlddraaaJ; Fbov.>t (�e�__CW L�' nP1 3Lid 1 ,zPnonw9�S-313-54110 <br /> " <br /> Consldtard t Sum CenaaaerA-epnq&-bc,lt Ada19a�lDi IAk y .17�tACdY A 1.w0 Phenee5R-10-4/00 <br /> OIs COadlnata•:X ,Y ToknaMP�► Ranf• lowSaefen <br /> YYORII TO 9E PERFORMED <br /> `)NEW WELL i 60RING(CPT,GEOPROBC.HYDROPUNCH.NANO-AUGER,OTHER') 0 GESTRUCTION(VERAI E blow) <br /> Q SOIL BORING Is O PIlESBIWE GROUT <br /> rodtar <br /> COMMENTS: <br /> LYPEoIEWL VOTALLATIOM TYPE COMB fP T10r18 y <br /> jego lrr AINO ;IOILOW STEM DIA.OF IOREt10lE MULTIPLE CABINGST Q YES XNO WELL CA81NO DW- <br /> D EXTRACTION 0 MR HAMMERIDRIVEN CAMW THICKNESS TYPE OF CASINO: Q STEEL xF/C Q OTHER: <br /> D VAPOR D muo ROTARY DEPTH OF GROUT SFAL-AS-fZ' TREME TYPE TO BE USED: OHOSE <br /> Q AIR SPARGE O PUSH POINT GROUT SEAL PUMPED: Q Ya .w+^ (NOTE: MAXIMUM FREE ALL DEPTH IS]0') <br /> Q SOIL BORING O RANO AUGER APPR03C.BORING OEPTH J,4_��OLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: O OTHER CONDUCTOR CASING PROPOSEW-11D—f II YES.list apodficadans ham): <br /> CONMNTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hem"c.mty 1119111 iwa prepared this"pikeflo,and Ma11119 wall will be datr In attardanM w0h Hart Jwquin County Om7nantra,Scale Lalaa,and Rules <br /> and Regulation Or Ina San Joaquin '(aunty. Hom uses M a imaw levea it algnaa m c~tM bYawMp:-1 arab that in 06 P•ryrrB••c•of 1119 was <br /> kv which d"s pomw 4 4 A"100 Bat erwploy Persona"Wed to WORREW COMPSMATM Lawn of Cadlbndo.' Cant lGlda Wft a suh• <br /> !WAtum Mffl"8M POMOwktg:Y OaAdy d19t 7111119 PartOmWW.d M.wok br wldpn Uwe pelmd h 4auad,7 ud19d ampby paraorp aub�ct m <br /> v110 s <br /> AP TLava aCa MUST UiT GALL 4a MRS IN ADVANCE FOR ALL REQUIRED iNiPEGTtONS/. <br /> Signed x �' � red <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATE Mam 114} I'lf I <br /> OCPART1E71T U8E ONLY /11{/[l, <br /> AppMZW-Aoppted By Dots laauad� Asea //S/�/,$)-(7- <br /> Graut Inspection BY Dao PInM s1y19erNn �Oale���o_od <br /> peatruQipn Inspection B DMO <br /> COMMENT!1 CONDITIONS: <br /> F <br /> ACCOUNTING ONLY: Af]a <br /> pE CODES FEE INFO I AMOUNT REYOTED CNBCKMCASH RgCZMMBY DATE PERMRI8ERVICE REQUEBT NUMBER INVOICE <br /> is <br /> UNIT N-6/23M9 16"bhpgllAI <br />