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tm z <br /> DRIGWAL <br /> 07/7l/9A SPED 11:56 FAX o10 663 6350 GEOBATRiX 0AICLAND <br /> - r <br /> WELL PERMIT APPLICATION FO <br /> SAN JOAQUIN COUNTY P.UBUC HEALTH SER00 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 TAR FllolA_OATE KSUFA <br /> Application a 1100011Y MOM to San Jaequu County for a punk Is WnsaW sntlJpr eutM ttw wo*deacnoad. This apphcallon is made In tartpA ono*" <br /> San Joaquin COUM OavelOpntam TMe.Chapter 2-1115.3 and the 8nndenta of San JcagON County Pubec HeaNO SWICSS'Atli Has"06is O <br /> or a <br /> WELL LocatlOa 2ASS !De tYse-f s�rA-_cbaa sn+.c�Q1n• � LP.Y�e3/ �%�Panar ?J5B�3 Z <br /> PROPERTY owner F ,1 C'fY;au�e(� Addreealj r' IDfin ckYSG �ap��JJ¢Phenw2o4- Z�71C1� <br /> C47Comracmr&'dO iilPwn JlddraaaJ; Fbov.>t (�e�__CW L'1i nPl 3Lid 1 ,zPnonw9�S-313-54do <br /> y ��lJa." �� ' <br /> Conudtartt/Sue CenaaaerA-epnq&-bc,lt Adar«.�1Di IAk y .17�P1r CdYyC .Ice Phenee5R-10-JAC0 <br /> GIs COaMnata•:X ,Y TodnwlP�► Ranga low S.men <br /> worn TO 9E➢'ERFORMED <br /> )IEMI WELL i 60RING(CPT,GEOPROBC.HYDROPUNCH.NANO-AUGER,OTHER') 0 DESTRUCTION(VERAI E O.low) <br /> Q SOIL BORING Is Q PIlESBIWE GROUT <br /> rotnar <br /> COMMENTS: <br /> LYPEoIEWL VOTALLATNON TYPE COMB fP TeoNB y <br /> jego lrr AINO ;IOILOW STEM DIA.OF IOREt10lE MULTIPLE CABINGST Q YES XNO WELL CASINO DW- <br /> D EXTRACTION 0 MR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASINO: Q STEEL xF/C Q OTHER: OHO <br /> D VAPOR D muo ROTARY DEPTH OF GROUT SFAL-AS-Z' TREME TYPE TO eE USED: y. OSE <br /> Q AIR SPARCE Q PUSH POINT GROUT SEAL PUTAPEO: Q Yes :g-& (NOTE: MAXIMUM FREE ALL DEPTH IS 3W) <br /> Q SOIL BORING Q HANO AUGER APPR03C.BORING OEPTN J,4_��OLTED TRAFFIC BOX or Q STOVE PIPE <br /> Q OTHER: Q OTHER CONDUCTOR CASING PROPOSEW-11D—f If YES.list apodficadans ham): <br /> CONMNTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hem"welh 1119111 iwe pr.pared this"pikeflo,and IhM lh.wall will be dalr In 6Ctard8n4*w0h Bart Jwquin County Omtnantra,Scale Lean,and Rules <br /> and Regulation Of Ina San Joaquin '(aunty. HdnisawnM a imaad a8earit a1MnMIm csrMlaa tM loacaratp:-1 cw ft deer in 06 P•ryrrn••c•of the was <br /> Ir which dw!pomw 4 4 A"100 Bat employ Persona"Wed to WORREW COMPBNSATM Lawn of Cerllbndo.' Cantratlda Wft a suh• <br /> !WAtum Mffl"MO ft"911 tg:Y OaAdy dud In Ne PartomWW.or M.waif h!wldpn Boa parmd It/aaiisd,!anad ampby paraorta aubj•c1 tovw s AP T Lava aCa MUST UiT GALL 4a HRis IN ADVANCE FOR ALL REQUIRED iNiPEGTtONS/. <br /> Signed a �' —'� red <br /> SEE SITE MAP IN UNIT IV WORK PLAN DATE Mam 114} I'lf I <br /> OCPARTiB:71T U8E ONLY /11{/[l, <br /> Appdcatlon Adapted By DMs laauad� Aaea //S/�/,$)-(7- <br /> Graul Inspection By pact PRAM 41yiserNn �Oale���o_od <br /> peatruQipn Inspection B DMO <br /> COMMENT!I CONDITIONS: <br /> F <br /> ACCOUNTING ONLY: Af]e <br /> pE CODES FEE INFO I AMOUNT REYOTED CNBCKMCASH RgCZM MBY DATE PERYRI8ERVICE REQUEBT NUMBER INVOICE <br /> is <br /> UNIT N-h/23M9 16"bhpgllAI <br />