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r <br /> 06/07/00 13:34 FAX 407 650 3639, •NNN LEGAL_. <br /> WELL PERMITAPPLICATION FORM LIN IT IV <br /> r <br /> SAN .IOAQUIN COUNTY PUBLIC HEALTH t�HEHD SERVICES Q I <br /> ENVIRONMENTAL HEALTHIDIV ( 96�0� <br /> 304 E. Weber.Third Floor, Stockton, CA,., <br /> (209) 468-3449 / <br /> EXP EJ! YEA ROM 7 <br /> NO f+IDAB EIcation Is made In 120.01 nth Sen <br /> Application Is hereby made to san JDaquin county for a permit to construct andtOr fn5ta11 <br /> the iaarlc descrit�ed, This apP1 <br /> Joaquin Cougty l7eve1cpm6nt Title,ChBptier 9-1145.3 and Me Sfsndarda of Sen.JOIE iln County Public Health Services,EnvironmenlaallHHe$altth Division. <br /> Crast 7-Z01 city .TRAe- Zip 952,71 Parcell[236'c3z[3-to'L <br /> I) <br /> WFILL Loeat[en 1d t3 f Mp 47_801 +4 07 Lo 11�4 <br /> PROP ERV Owner <br /> Address , a dip. city aPtar�Ga <br /> C-57 carttractor ISQ C- Addre- <br /> 23 C'u MM �tE .Gle. Cly G P�riUI�i Lid#�RR`�06 Phom 911 Qoq-�2: <br /> k"-5-t r-# I,22108 Pham Cao 4105-8712 <br /> ConsuliarM 1 suit Ccn&2cWr <br /> �7 �,4ta7 SeDtlon I <br /> Townefilp s 50LIT" Ftrrn9a <br /> GLS GoordinatIII 7C 'Y <br /> [NOR TOB PE <br /> E5TRUCTIOM[choose type below r <br /> TJ NEW WELL J BDI$ING{CPT.GEOPRO13t=,FiYOROPUNCH.HANd-AUGER,r]THII ROVER-AORE <br /> oiL BORING# �F � I ❑PRESSURE GROUT <br /> "other; <br /> COMMENTS: <br /> IN LAT[ N E CON5TRLJ ON§ff9@IFIGATIONS ,, <br /> -�ELL DLA.OF BdREHOLp �a Irq MULTIPLE GASlNG57 CI S NO WEft GAStNG DIA: Z <br /> MONITORING HOLLOW STEW _ <br /> EXTRACTION AlR HAMMERIORI IEfV CASINGTHICKNESS SCS—TYPE 01�IEN�TO UE USED: CRr �I IOSE <br /> []VAPQRd MUD ROTARY DEPTH OF GROUT III,Q AIR gppyRGE ()Pl7SW POINT GRour sEAL PUMPEo- Yes NQ (NCtTE: MA�ClAAUM FREE-�A4.UGEFZS <br /> LL 13F-PTH IS 30') <br /> HAND AUGER APPRO}L PORING DFS t' 130��TRAFFIC 809 " STOVE PIPE <br /> Q SOIL BORING CONQUCTOR CASING'PROPOSED? � <br /> ^(it YES,list spedtian5 here)- I: <br /> OTHER: ._��OTHER�r <br /> cOdtiM1=NT'S- <br /> NOTE: OFFSITE BORINGS REC.UIFRE ACCESS OR ENICROACHMENT PERMITS � <br /> e La%vs,and RL'Ies <br /> 1 hereby meft that I have prepared this ePPII'�t1an and that the Work will be done in aGcordanoE wlrh Joagtuv Coy�DIin map 'i ancof rTre we k <br /> lure certifies the#aliosnir>9: r�Y a Contrar�ors hiring Oct 1I <br /> and Regulations of III San JDagUfn ODrJnty_ Hvmeovmar tai�ineIIIII�R ,C�pENSA71c)NLAWS OfCalltbrnia- <br /> rorwhich This Perr�aRl is fgyued,I shag not ernplOy s nk for which dhis punTa is is.9usd,I ahsll employ persons subjod to <br /> (Minnding signaturo CWtisas the f0IIQWiA9' y certify tttdt In the perforrrn�rrce of fhs Ivo <br /> WORKERS,c MMNSATION i4ws Of Galifarnia.• . <br /> } ► IN PECTOR 4B WORKING HRS i1N ADVANCE i"'�R ALL REQUIRED INSPECTIONS <br /> L THE UNIT IV f�� • k <br /> c��t" � rinercomPan,r-s'�?•�}►-��y(y►sr. /<iZF!-Z�9�t+' <br /> Mgnad K flats Z`&OL> <br /> ' -... <br /> S <br /> J L,' •1' �/�/:-fes S <br /> Print Name <br /> i' Eon- _.. ^• `--;:�^�,;��' — :- �S�•.�_�J`..i ��;_';3�-�•,c-•`:r_ <br /> �• ��._a„,r <br /> p p ECJ7 E ONl_ �.Z, =O v � e3 <br /> ON <br /> DafielssuedL .y 7y pp <br /> ApPllcation Aaoapted DY pates Final Inspecth"BY <br /> rout Irmwpedlon By DEtn ; } <br /> Desmition Inspection By <br /> Y <br /> coMMENTS 1 CO>hI113MON : <br /> ACCOUNTING ONLY: AID <br /> GHEGKO REG'DBY DAIS PF-RNRI 1SrRVICE�REQUEST I# IfIVO10E <br /> PE CODES FEE INEO r I 7 AMOUNT ReNffT I b F `— 91 Q 0 3 V q b <br /> Zq L �D641 5f 1'7/®D <br /> 0 <br /> G57 exQ.f. 1hlCtuuQi�e�� C-57 Lester of Author;z rL to sign perrfrit ✓ Encroachment.dot(O. <br /> i�IaO� Hl-41A 5£b85gb61d f?E=bt 0017Z/90f9H <br />