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SAX !U'ACUIH CGOUTY PUBLIC HEALTH SERVICES <br /> -- V1HUNMFVTAL HEALTH DIVISICU <br /> Aba-- <br /> - - STOCXTUH, CA SSZDl j +'3 <br /> XFWD QIG, L <br /> RE�aUAetf L.�E maZ�Ra FRCS F 1S <br /> Appl Tcatim is here Sy matie to the San Jaayvin Csrcy 'or as Perm—t andyar IrscatL the Nark dVfi Sed. ThisaFIFn;Hm is <br /> aade in ccotiame with San Joaquin Cointy Oeveix+ent Ticl Chapter 9-1115.3 and the Starrards of San doegJin Catnty p,,s l< Neai:i <br /> Services, °.rwironaentaL Health 7ivisirn. / <br /> Job Adrras:/or A?Ns 5400 TaA('TPT( AVPn1TP city Stockton Parcel Site/Apue AW M.I��`�/J/� <br /> /-3 <br /> � Phone f <br /> r'a Rarae Montgomery Ward Acorea: 5400 Pacific Avenue 714/7736227 <br /> CzatreatorEnvironmental Audit, IAgfe. 1 OOOA Ortega 1Alay Lit., 606348 phere s 714/632-8521 <br /> sm emcrae ar V & -W Drilling Address Monier Park Place LFG 720904 Ph«. x 707/374-2815 <br /> R ' n V ' f !'A <br /> TTPS OF '.ELL/PIJMPt & XEy '.ELL ❑ RE-LACIEHT LELL .i MONITORING YELLS ❑ OTHER <br /> ❑ DESTRLH^ILW ❑ WT-OF-SERVICE '.ELL ❑ GEOPHTSICAL WELL i' '❑ SOIL 6OR[NG <br /> INSTALUTICH ❑ — SYSTE4 REPAIR ❑ CROSS-C1:HHECT REPAIR. vAPCR EXTuc-ION i11Z•,T-6 <br /> G Naw ❑ Repeir H.P. OE?TH Pla1P SET FT, FIRST WATER L=VEL to VEW-1 3 <br /> (TYPE OF A" <br /> RTEXDED M TTPE OF WELL COXSTRUCTIOX SPEC:FHCITIOXS <br /> 101, <br /> E3INIXAiRIli ❑ CPEH eCTTCN OIA. OF LELL EXCAVATION DIA. OF C^XJUC'.C2 GS1MG <br /> ❑ DOt£STIC/PRIVATE 1 GRAVEL PACK/Sr`_ T(P£ 0; USI)IG/STEEL/PVC PVC: DIA. OF '.ELL USING 11,/211 <br /> /9RJH/j�jI PAL G DRIVEN DE?TH OF GROUT SEAL 30-55 14-2 SPECIFIUTZICH <br /> ':�G 9 OTHER GRWT Sc,LL INSTALLS 9T T GZCUT MAIMNAHE <br /> MCNITCRING GRarr SEAL PlJ1lpED: es CCOICREiE P©ESTAL BY DRILLER: es G Na <br /> APP911X 08rtN 60 LING CHESTER 8CX/S.CVE PIPE <br /> PROPOSED CCXSTRICTIOXIORILLING X'FROO: MLZ ACTA:T_ AIR ROTARY_ AUGER. X U3L= GTHER_ <br /> I hereoy certify mat I have ;ra^-arW :ais acct:nctm aM Ltac cne work wiLL be done in a coreance wi t4 San Joawin Cxnry Czinarees, <br /> state Laws, arid zutes and ReSul atians of Lhe San :oeGin Canty. Nome owner or Lic_-rzed a5ent's sisra:jrt certifies the fcllcvint: '• <br /> certify that in the perfo� of the work for wnid _his pamit is issued, I shall not e:otcy persons Stnieet:to lt.,OUWIS CDMP1'HSATICH' <br /> Laws of California.- Cmcractor's hiring or s—cenc. e=m signature certifies the foi Lowing: • I certify :hat in tha pe^ar—axe <br /> of the rerk for which this perseit is issued, I C:aLL emo(ey persons subiec: to LCRKMANr2 m4PEH5ATICH Laws of Ca Lifcrnia.• 7N1 AP?UG)(T' <br /> MUST CALL 24 URS IN AOVAXM F1D*11C�lZOUIR£U a ECIIOYS AT QO91 488-2_17. C000leta drawirg aa- Lower area provided. �+ <br /> Si9:uC X � i Hideit�l C Dace Ste/ F <br /> J <br /> 1111111 ! IIII II F ! ! ii ! <br /> IIIIIIIII ( ! <br /> At ALIII Iill <br /> IIII ! Iililli ! ! � ! II ! ! 1111 <br /> DEPART1tEXT USE OXIT ��•� Je <br /> at <br /> Hopi icacim ed r <br /> AcceptBy Dat A <br /> Grout Irapectim 31 Dace Pt. Ins .tim by Once: <br /> Ocstvctim Inspection 8y Once Coaven[s: <br /> E <br /> ACC9UXT➢I6 DMLY: A10= FACT <br /> P£ c2m I FSE IJIFG AMOUNT Re T'I'm ! CLECXf.=SH ! RECEIVED By DAY, I ?ERMTTIS REQUEST XUMeER I INVOKE <br /> ICAItsI I I <br /> I ! <br /> I i f I ! I i <br />