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i PAYMENT <br /> RECEIVED <br /> SAA:OA2UIN COUNTY PUEJC 14EALTH SERYICZS <br /> ESYIRLINMC ENTAL HEALTH DIYISI011 C P ?2 7 1994 <br /> P O SOX 388, t:E It SAA JOAOUIN 5% STOCXTOA,CA SE201388 SAN jDAQU;N GOi,!NTY <br /> 2091 ossa= PUBLIC HEAL?I Sr RV CES <br /> Ef-0VIRONMGNTAF HPAt TH DIVISION <br /> Moa-AEFmk2tf PIAT EXPIFE4 1 TE1A FaP�•�ATE ISSVED <br /> IFaavlan w icpLwo! <br /> tWlieatian {e here !al ode Le the San :osquln C�tY to.- s ptrmit to corsTrucz atd/or SratALl the Nerk described- Thls application is <br /> rade in =VLlance aIrh San Joaquin county De'Lopic t T'.tlt, ChaPW 9.1115.3 and VN Standards at San JoegWin CwNUry PlClfc NeNI�- <br /> Ler-ices, £miror rat Health Divitl*r- <br /> ;Ity Stockton (W3- - <br /> 1448 Shaw Road <br /> ICS Addreas(ar APNa Pare![ Si RelAPlie <br /> 7Yner-s Nyco u5 Chemical L•d tv 1448 Shaw Road, Stockton Phone S_209/948-3035 <br /> :Antrattee West Hazmat Drilling uvr+ ate 3323 P'_tLgerald St. Lict554979 phonel9i6/638-7276 <br /> Rancho Cordova, CA 95/4w Phone <br /> pb Contractor <br /> rtAE OF SELL /PUNPI ❑ NEW UELL ❑ RvtL-` w WELL Q "17M!NS WELL S ❑ OTHER <br /> C DESTR[ICT 10N C CIR �3 <br /> -Dr-: YILE YELL C MOPBTSICAL WELL XX 50IL BORING 7 <br /> ❑ INSTALLATION ❑ +£LL rSTE)1 REPAIR C CROSS-COWECT REPAIR ❑ VAPOR EMACTIOII %ML V <br /> ❑ Nt i I3 Rrpeir N.P. DEPTH PIRP 3[t fT. FIRST YATE4 LEYEL <br /> CTTPE OF PLAR) <br /> �frrERDED DSE TYPE OF WEE coxyR=WR SPECIFICATWNi <br /> DIA. OF CONOCCIM CASING <br /> p INDUSTRIAL G OPEN BOTTOM DIA. OF skLt E10.lYATIibI I -� <br /> OF i7 <br /> ❑ <br /> DIA. OF UELL CASING <br /> DOIESTICJPRIVATE C GRA4£ PACCl312£�� PE CA52NG/3TEkL/PRC 'V <br /> ❑ PWBLlf./FOIW IC[➢AL ❑ 7RIYEk <br /> ;CPTH OF DtOUT SEAL SPECIFICATICII <br /> p IRRIGATION/AG ❑ OTHER GMM SEAL INSTALLED Bt CRan' BRAND NAME <br /> ❑ !YYiiTp[I NG <br /> GMT SEAL P1DtP-M: ❑ Tes ❑ No CCMCRETE PEDESIAL r DRILLER: ❑ TC ❑ No <br /> APPNXL DEPTH LOCOING CHESTER DDNISMrl PIPE ^n <br /> PROPOSED CORSTROCiiORIORILLLHG iEESAOD: MD WA4T_ AIR NOTARY_Aura-'!- CAALE_ 07HER— �) <br /> MwaT <br /> in <br /> mffTrT <br /> I hereby certify thet I havc Prepared this aFQLicazion;nd thit 8ttat kaN,[T Li'��aa iysNture lcer[ iestthe foQla..si =L <br /> State lei, and I., p and Regu[ssrione of the SYI ie' t _ I shall rat a pLoy persons subi�' to�WRMAN'5 CypflISATIOS <br /> c<rtlfy that in tfie per4orme:rs of the Weft far +Ein thss permit it laved, that in the perfnrsancs <br /> La,a of California." Contractarrs hin4na or ubcxl:ractirq=� �er tature s tVL:RA7lt%'54aCC"EVSATIOa Ia�ULifornia.o THE APPUCW pm <br /> of the cork for sdlt IN this permit is issued, &VLoy P� Leto draNinH At lover area W6yi ded_ <br /> MUST CALL Zi AO it51X A Y FOR ALL AFDUJAEO rySP6'TANS AT G!aW Affi.1121. Ca^/4 <br /> S59ntd t r R?jn ur /-/f�/ C.G Title4- 1 1 1 1 <br /> H7�H± <br /> I <br /> 1 <br /> II I <br /> DEPARTMW USE ONLY <br /> Dam t�i ,Pta <br /> ApplleN[Ien Ae�Pted sy <br /> P,,P Inspection By bete <br /> Lion By <br /> Wart IMPeD Date �I'L< 'P5 Cumrcv+rse 7 �igS ./-•`, <br /> Des-Mien Inspection 6y "—`—y—T �] <br /> ACCDUaT7NG ONLY: <br /> AIDS! <br /> D <br /> ALD <br /> PE CODES FEE fAFO AJfOONT StUIlTED CRE=ZuSN EECUM BT DATE PEAsI[T13FSYKE alOUE3T It0i[SS3 IRYOICE <br /> z9 0 l 8 s d yl -Z7� <br /> 1 <br /> a i <br /> 20"d �29S79s9TST D-1 WOa--j bH317:0T 5b6T-52-E0 <br /> goo fn :.L213AVHDvS PTH CC9ST9C9T6T.Q 6S:tT tsl9ZJ60 <br />