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MAY-20-2002 03:19P FROM: <br /> TO:19163834t7�4 r�ti'� <br /> WELL PERMIT APPLICATION FORM SITE TION <br /> WEIVIITIGA <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH 5FMACES UNIT IV <br /> ENVIRONMENTAL <br /> DIVISION (PHS EHD) <br /> 304 p.Weber+Third Floor, Stocktonl GA•+85202 <br /> (209)468-3449 <br /> made in�anpfianu tvi7+Sah <br /> rk daaattted. TM! ic".7tbn is t+fm prv;ston. <br /> CosNIH a �oonfatl�endlbr Initas tluwo � <br /> tppap5on K henaY mad!to San Joaquin Public Health Services.Em��Of'�eSbOel I oq-o?S <br /> b county robeDevMa int Tisk.Chapter g t 11s.3 and the Stands+d!of San Jooquin Caa+y `wrn 9--Pame C <br /> NELL Le i q i'f(� 1.1. 4� 1► <br /> 9q CroSa streets�ivtb Gty Phonsll a <br /> MOPERTYOwner M`tete.mL 12 <br /> .5 <br /> �.-ladress; - <br /> j <br /> 'p— <br /> .-W <br /> C.Z n16ro phon6a 3 ' <br /> c-ST Cortaaetar Z,a(1,M 115 s �1 City �te'e uca,^-�'� <br /> taQ 1p:E�Aadral _ secaon 3/ <br /> Co"Su nt t 3ub CoRtradar��— TownlhlP 4N R0W 7F <br /> 013 Coaaisatec_ <br /> Y <br /> Q DES7RUCTIOt► �E <br /> IWIO"'} <br /> }IY MpUNCH.MD-AUGER.OTHNRI 0 <br /> 1!(PRESSl1RE GROUT <br /> EW W <br /> ELL 190RIlIGi(CPz.OEOPRO�E' . srt- t 0 <br /> SOIL 6ORIP13« <br /> U WELL II Qrou15Vk'nu6ons: <br /> rottf�R <br /> COMMENT ' T <br /> MULTIPLE CASINW Q Ylxa No WELL C41NG OIA.�_ <br /> TrvE� T Ou,.of MEL p PVC 13 OT"Ifk_ — <br /> Q MONITORING D HOLLOW STIM MIG THO*SfSS,���TYPE OF CAS p HOSE <br /> OEXMACTiON 0 AIR MANIMEWORNN PTH OF GRMT TREMIE TYPE TO M U tE p AUCiDE 0 <br /> C VAPOR p LAUD ROTARY f SEAL PUMPeot Dyes p No (NOTE:MAXIMUM FREE-FALL OEPYN i8 X0'1 <br /> 0 AIR SPARGE p PUSH POINT <br /> GMMT SPECIFICATIONf: p WXT90 TRAFFIC SOX ar p sTovE PIPE <br /> p SOIL BORING HAND <br /> APPROX.8"r-orzM <br /> OTHER^ OFtIN (N YES.051"oddca6art0 herek <br /> CONDUCTOR CASING P'ROPOSEDI— . <br /> -COµIY1ENTS: <br /> • OFFSITE BORINGS REQUIRE ACCESS OR TENOR ALL R 0UIREo NS ECTIONS' <br /> NOTE. <br /> CALL TM UNIT 1V 1 CTOR 481NORKING HOURS i3--iii ADVAN <br /> application and that the W9A"ill bs don° In>lt:corda"as with San Joaquin <br /> 1 h at 1 hates red this <br /> Co Iy phi cas, t RegutaUont:,and ali applicable CalNomia State Laws. e�L � a � , <br /> Tlee+comas�r i`�"" "°D — <br /> >t ata <br /> Sip o <br /> Print NaJs D T N U O <br /> SiTo MAP IN UNIT IV FILE,ApORF-SS: <br /> WORK PLAN OATI=O: , n T �� <br /> care arred <br /> Appo"llon Awspled BY DaM Final Inspat3i0rt By <br /> Great in>wectio+by pa <br /> Dlsastehon H <br /> COMMMTS i CONDMONI <br /> ACCOUNTING ONLY: AIDS Tp CMEKO <br /> ' Y GATE PEMlT f aERV <br /> E REQUST S INVOICE <br /> pECOM Menso jjk RIT <br /> - 2-IN 91 3 t g 1o it9t+ . E -E"`roothment doe` <br /> ��I.tfAr of AUth <br />