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Dec-22 99 03 : 18P V-V i UU9 ov- i l l i ng 926 ,_5 6678 P .06 <br /> FA PDD <br /> v <br /> WELL PERMIT APPLICATION FARM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION(PHS-KHM ORIGINAL <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (249) 488-3445 <br /> dll EXPIRES Y R FR M DATE JSSUED <br /> avm:cerion:•s merely made W San Joswrl County w a perm!!to conatrua andror In"Iss:he work destrtbea This apptearlon.s meas et cortrGuar'ct wi n <br /> San Jaaauln County Develo0MIII♦Title,Criaote 6.1115.3 and the Stanaards of San Joaq <br /> u <br /> in County Ppup,a)G Health Serwicas,Env ram*rBrnai Meakin u vrc�ry <br /> WELL LoeeYort 11�kc P ItD RD Crate Slrnet I r�At� auur.ky f GT tr95p��7g�,,�Asseeew f; <br /> PROPERT*OwOfOr.RE1 ., Ql� l 5 . A3tlroesl�•aI .�Pf'r O��V�_Cky ?•1 Am Z.ip�,Phcno#�f •��'.. - 52-•' <br /> C.ST Contract, - A adrers j' C tyc-s —2 eat r2;"6 W-6 10 3 <br /> Gonau+taniiSib Cawaacr e..i /radreasjjr,0 Irk Ar C". tC p!10^Cyr 7c7 _77y3 <br /> CIS Coordinates x —-•Y TerwtatlRP Range Soot-on <br /> WORK f2!i6 PjRF0R1ATLQ - 7 V t: t <br /> 7 nr=wWELL r 9GRJW3(CPT. GEOPROBE.HYDROPUNCH•HAND-AUGER.OrKER-) a DESTRUCTION(choose type bel:w <br /> WOLBt?R�NG* DEC 31 1999 °R <br /> ML ss AE`(;ROu- <br /> RAORt <br /> p WHEEL 0 <br /> 'Other. <br /> OF WELL IN <br /> jjmoKTOFVNG a HOLLOW STEM Dtk OF BOREHOLF— ttJ &Gr��YE �NO VYELL CASING,CIA-- <br /> j)EXTRAGTICNJ a AIR IiAN9dER10FdVEN CASIN(3 THICKNESS�.TYPE OF CASING: a STEEL d DVI: a OTHER <br /> a VAPOR: fl MUM ROTARY 0EPTti AF GROUP SEAL!_TREM IE TYPE TOGS USED: p AUGERS n-105� <br /> jI A;R SPARGE I RUSH POWT GROUT SEAL PLIWED: a Ya• No (NOPE:MAXIMUM FREE-FALL DOPTH IS 3ID'i <br /> jt SOIL BEfRWG a RANO AW5ER APPROXI BORING DEPTH Z5.0' a 501.1'Ep TWFIC Box Dr Q STC)VE PIPE <br /> a C-}iEFL d OTHER__ CokoUtrW CASING PROPOSED? X100 t H YEP,ilat epenfk=ion6 here R' <br /> COMMENTS: f s'r — — <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHmeNT PERIIMTS <br /> I Whinny nartty trlaT 1"vA PFAAAxtd Inns appilca6 t and that Ira work wria be dme sn sewf anew srdh Eat%Jeaquin Qouity Ordinancel State Lay.!.aro. utas <br /> ana RApws?Bons et the s:n Jtleq in Caurdy Hornaawnfr or tkansad agant'a signstUre o0fta the toliavrng: 1)cer6fyOW Jn she partum ncf of rw work <br /> kr which This permit is tsa ma t shaft not frroay peraams shyest to WORKERS'Ct ASPENSAVON C*wa of CAINornla." OWnlr*cIcr t h sing ar pub <br /> wrdracting signatu tow Holies the fWov tnq: 'I cw*that in the performance of ft work ICY which rm pormd ie Au wKf,r shm'Arnpky persprta twJ*r PG+ <br /> INORIG£AS'GOJI+IPE'NSATIOJii Lawn of CaJr7omia.• _ <br /> ►Cid' i. 'iP1t ']F•` I ' Q�B• !� <br /> Title— <br /> Is <br /> SEE SITE M NIT IV WORK PLAN DATED: <br /> OVARTWNT usa owy <br /> App`edban A=cited BY __--- _, Date WvaO l '�U Area <br /> :rout hsapecdlon By Date� _�Inel tnapecdon 13y ED <br /> t]sst•idre'n L'1WstYlon 8 Dile <br /> GfOMMCNTBrpOAeQrrlprVB: ......,�. _ _-- -. r <br /> ACCOUNTING ONLY: AIDE <br /> 1 <br /> PE CODES I FI N ImFQ AAfOUHT AEIYNTT�i£1 CHECK M REC'C BY CATS PEJ4t8T!SEF[y10E REQUEST• INVOICE <br /> SJtiIT IV'-61Z3 t99/sign bl,WML <br /> Z •q WOLF Wd00°£ 66Gi—tiG—�# <br />