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l <br /> 04/252002 68 21� GEOLOOP DRILLING + 19165654356 <br /> NO.079 ©06 <br /> " � • . � , <br /> i r' <br /> WELL PERMIT APPLICATION FORM SITE <br /> ' SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES MITIGATION <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) UNIT IV <br /> ' 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> 11,111(!1 1111111 Nni <br /> Aeanarr rs hereby made to San Joaqukt Couu*for a permit to conatruct and/or instal!tho work dote bed 1Th a apPheauan io nlsda in compliance with San <br /> (urn County Davelopmenl Tilla,Chapter u-m s 3 And rya Slbndards of San Joaquin county Public Health Services,Envuonmewai Heam Division <br /> LU I_aaaticn �..��Q _ <br /> Croas Street _ City aVc r��JZip_�"I Aasesgor` <br /> 00PERTY0Pa reA <br /> w Br y– V�i.�+R }�Addrsss�Z & aAg ff',�.+ I ' <br /> �L'Iry ..�Zly 9.Phnna�r,,,.� <br /> Conffactor <br /> sultarn/Subcontractor Z_ � <br /> b <br /> Coordinates X--_, Township Ran k= <br /> 4 Sacuon <br /> 4OBE PERFORM p- <br /> EW WELLJ80RING CPT GEdpRQg[;,HWR DUNG HANa-RUL3ER�DTiiER'1 <br /> Sail SPRJ VG� - - - .iQ.I�E�.T1is,1QTT TN(9hQQMtym liaiotaca __ _ <br /> p WELL# �" p ov>macipl <br /> �tner <br /> MENTS Sc ou(r Groutspecrfieetloes D PgESSUFE GROUT <br /> Ol"VYEL I s hLr Div M STR <br /> MONITORING )(HOLLOW STEM DIA OF5 REH0 l <br /> 1*10 <br /> Tft7N [J AIR Fi{yMMEWDRIVEN CASING TRICKINESS MULTIPLE CASINGS Q YES `NO Vv><LL CASINt; olA - <br /> TYPE OF CASING [I STEEL PVC <br /> Q MUD ROTARY r I7 ❑OTHER <br /> DEPTH OF GROUT SEAL. / TREMIE TYPE TO BE USED ()AUGERS WHOSE <br /> VR SPARGE p PUSH POINT GROUT SEAL PUMFPED gYes D No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> IL BORING U HAND AUGER GAOU'r SPECIFICATIONS ice_ <br /> MER_— fl OTHER AppROX BORING DEPTH ti <br /> (I BOLTED TRAFRC BOX or j)STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? NJ (of YES,list specdicatiolns hers) <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERI 1fS__ <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS, <br /> Ireby certify that I have prepared this s licatlon and that the work <br /> aunty Ordlnerr ccs, Rules and Ragulatto ape d all applicable Ca tornlal S ate be Law n accordance with San Joaquin <br /> �T7if efCo a <br /> �` � -��---_,_w rip ►tY��,�'�'-�C' L� � �..L�ti�F`t rI'L~t i� ,�l�u� <br /> it Name C AY► tit `�— <br /> Date_______` — 2 <br /> DEPARTMENT USE ONLY — <br /> MAP IN UNIT IV FILE,ADDRESS; <br /> K PLAN DATED;��2� <br /> Iron Accepled Bye w Data Issued f?�'�� <br /> ut Inspection ay Area _ <br /> ection By <br /> bats Final Inspection By -- __-- — Date— <br /> q '9/CONVIT101I Dgt$ <br /> O PlTING ONLY AIDE! <br /> card <br /> ODES FEE INFO AMOUNT REMITTED CHECK# REWD SY DATE PERMIT/SERVICC REOLIII INVOICE <br /> WC -WaTVi:R G-57 tetter of Authorization to sign permit � ncroachment do 9/27/00 <br />