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MAY-20-2002 03:18P FROM: TD:191,63834084 P:3/5 <br /> WELL PERMIT APPLICATION FORM T ATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br /> 5.ENVIRW Neber,Third F1�,S oQldon, CA.85202} <br /> 304 <br /> 304!r, <br /> (209)468.3449 <br /> This sp Aiod"is made in colnpa^u w17t Sen <br /> 1�pIfOtGOft b fltfi�Y mach <br /> to Sin COIIntY a pi^� <br /> t 1D apnotn,at so& M�ftali the��desafl0ed• ScrA"S.an`^" �s�sien. <br /> koOi►C,,nq De"bMte^t TWO.C tmPWr Ni.f 1 lti•3 and the 3tandarEt:of San Joiquln f otr+!Y P"tNic Hcatth Zip 95-&A.)' Pltxle�t <br /> NEN.4eeadw 14 Z$6 N 1 Cro»Street �•7oOD/ �Q.� r,D�FtiOnes <br /> �,/,,,-r r►G d Sv��Addms a M/t*yw+- cm��.--- <br /> >RplERTC Owmr 'a 9 Phonef►loq- -3570 <br /> &WAWA&^ P.a►�- ah� Zt2to _ <br /> ^.-ST Contractor c- <br /> Zt B � Address G?•2LI►+�si\,a GIT CNy�f =---U�- WflCntl <br /> Coria mm t sub Contradw Rir+Oa "7 Sides+ 3 <br /> ass coordMoba•!x <br /> Y Township <br /> mm <br /> Wam To tE p"ImL Gait.oTH1:1E� p oESTRucT�Npc OVER <br /> eeww) <br /> AwW wa1L!90Refd(CPT,GO*ltosE's.HYDRO N 7O 8•ppgSSURE GROUT <br /> *SOJL DORINO Nl <br /> p WELL t: Grout SPi� s' <br /> •0tt+«' <br /> COMMENTS' <br /> T <br /> TM - o„�oF f;of:�++oLa MULTIPLE CASINGS?a,�s d No WELL CASPIG I),A:� <br /> p a a MOLLoW STFM -----� TYPF of cnstNo: p sTEEL a� o OTMERi_____� <br /> NEN CASING TMtCiCNESS—.�—�- ��(E 1YPE TO 8E USED: V AU GERS a HC56 <br /> C EXTRACTION a AIR U R plgpTM OF GROUT SIALr..�—�.— <br /> pVAf'OR <br /> MUD ROTARY GROUT seALPUMs�n: QYu p� (NOTE; MAX <br /> 1MUM FRi<E-PALL DEPTH t53p') <br /> p AIR SPAaGP �PUSN POINT <br /> GRouT SM3CIF�►TfONS- STovE PIPE <br /> 7�eo"'yo p HANr?AUGER �Rox.gM4G DEPTH p saran TRAFFIC m$ �• 0 <br /> D OTHER-_� 0 OTMR��_— if YES,isd spodttcanens Iure� <br /> CONDUCTOR CA6tNG�pOSF�'1-�—� <br /> -COIAMOTS: <br /> NOTE- OFFSITE BORINGS REQUIRE ACCESS O GE AOR ALL REQ REO INCROACHNIENT S EC ONS. <br /> LTH NIT 1V INSP 4s WORKING HOURS IN ADVAN <br /> at 1 a fy thiS appileation and that the work wilt be done in accordance with San.losgviin <br /> I y eQuiations,and all applic&ble CaNtomin state Lows. dric <br /> )C Cou ty es, TNeK•�P�Y 14 tav_ • <br /> 99 <br /> Pont Hanle <br /> SIT6 MAP IN UNrr N F1L.E,ADDRESS: <br /> WORKPLAN DATED: <br /> � Dati hstrad <br /> Apoc&Uon Adapted BY f3au fk►sE inspe~8!r <br /> GoA tnipo"Br Oslo MUD <br /> CMTS!COl1fn'rtOMS: <br /> A00OUNTING ONLY: AJ0 E REQMS7 a INVOKE .� <br /> FU MFo AMOUNT RFjArrr<p CHICK s <br /> RECD 6Y DATE PERMIT�sER� <br /> t�CO�as <br /> 3�N�r0 <br /> e tr f A�tho�izo�ierlLa i9n�rmii�ncr_oach�t docs 9/2710 <br /> ■v uu� -WAIVE - C�� o ' <br />