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iy y <br /> Dec-22-99 03 ! 18P Kvituy Dri l l in9 9265 6678 <br /> P , 06. <br /> L F4 <br /> WELL PERMIT APPLICATION FORMUNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIYISICN {PHS-F-HO) <br /> 304 E.Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449cc <br /> T 2ZPIV=YEAR FRCM DATE 68SUEC <br /> Rnptrsoo-n'i hereby made no San JdaOuin Canty for a penrtn to Conatrua aiwor ieaias TIE work desG•1bea. This apomeanon 3.11aoeM CZ Y.aar-,L Ai;r, <br /> Sui Joacu•n C)L rty Development Tice, Cttwwr�6-1111,3 and the Stana&,=of San Jda4uln County P 511 H8210 Servic".Env rornrenta+Heaun I.;tim,rw <br /> w£LLLoaallon �� V � PILp PD -TRACYOAsse�sors <br /> C-WAstrnet ICAC_ gY G l V11m,�1I <br /> th� n n <br /> PROPERTY q„e,►r h E STl A3tlrsCa I20 i ( ��T3 Ayy° Gay IJ �1 M Zip9?5 Ph:nsylF 7!µ/�S$- S Z <br /> ALdre`>< aC+tY�C�.Z�1�..,�+Cx Nf .�nb� J,�• 6�'S 7j�I <br /> COnu+ <br /> ata+ri SSR Cantraacr��iLl Cit t <br /> nn'faQC.��ACdraeS 3�a 14M ST' coy 0 �P.10 7c7 7 77V <br /> SISCoortiinstee Y YTornahip 8iGl.on <br /> WORT(TO 4j.F'tuoRmsm, — �... <br /> 1 N«N WicLL+130RIW.i CPT. GEOPROW.HYWOPUNCH. HANC,+�UGER.OTll1t') Q DESTRUCTION fchoca»type tclav„ <br /> WOL BORING _ <br /> a WELL a DEC 31 1999 a PRESSURE C3RQJ- <br /> 'Other. <br /> COMMENT'. -TYPE-OF WE IN3TALLATIGft !QN 9pE TOtt al TLJ <br /> ahAON1TORING {]HOLLOW STEM DIA OF BG'RE-1CLZ o r <br /> Q EXTRACTION 113 AIR MANIMERIERIVEN CASING TMk^,Kz4E,R TYPE OF CASING {]STEEL a PVC a CTI-ER <br /> d VAPOR la 7dUD ROTAFIV DEPTH OF OROUY SEAL��TREIMIE TYPE TO gE U9EQ- R Au0E35 Cripgp� <br /> Q A R SPARGE §BUSH PC"T GROUT SEAL Pt*WED: p Y*• 1 No (NOPE:MAXIMUM FREE-FALL DEPTH IS 30'j <br /> �SCtL SORING a hAND k*ER APPROX, BORING Oe TT1 2-,5" <br /> Q t3ULT60 TRWFIC 8CX tx Q STCYE PIPE <br /> OTMER C0N0ucr0R CASING PRCPOSEO? Al D S.H Y£g.,;gt apee:Nealsons F+e,ei <br /> COMMENTS: f- ST � .. — <br /> ii NOTE: OFFSITE SORINGS REQUIRE ACCESS OR ENCROACHMENT PERNTS <br /> I:1M''Cy nervy tsar I hAvA rr"14a thts 2DINCI M and that tr0 work will be done m s=moanas wdh.`tae Joaquin Gau-lty Ords.-Tancez Stam!a,.i,tri+�uies <br /> snaRegula+coni If the San Jeagan Ca mtY ►+o'00NI r or aeamud ageM'a tgrrpbah o"#4 a the b1!a%vn --1 n <br /> for which this Arar+rrlt is+ 0+04 1 50011 flog v"ga Divst7rt8 2~to 9 refer Nret in JA•pwforrsunet Q(" <br /> wo-n <br /> WORKERS'CoAmU_ALr-A7707Y LaWR of CallltornAL" Conimety r h,rvig cr:�a <br /> earnraa�nq t pnatunt wriitiQs the FOlbwi np:'1 rsrMy flirt in fha Pwfarmartee of ery work far wroth Alp palm,is+Qeuvd, r snra wrrHleY PenOr s e'U,9,7 .b <br /> t•7roRKE+�S'COAu'E'NSATlCN L-0�rs d Ca►Tornia." <br /> THE' k ... i <br /> ,iig ' - Title `1 Dateza - <br /> SEE SITE M NIT IV WORK PLAN DATED: <br /> 36PAiCf'awT use.O1iLY <br /> iii��� Epnkxeon A.�cretcd!]y Date ls.,sd T'z00C.) 4raa <br /> Grout Inopaaian Is*,- Dale cMl Ih�pOttipn BI <br /> Ora#rva,cn 8 <br /> C0MF=NT2 r CON CrTIdNS; <br /> ACCOUNTING ONLY: AID1e --•- •_ _._ <br /> PE CODES j FIM IH FO AMOUW Ri ArM t 4nX s <br /> REC-0 GY HATE PEMOTf SERVICE REOU"T a INVC,ce <br /> 43 002/.5-70 <br /> UNIT 3Y-6%t3/99/sign bl,pglMl • ~ <br />