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x <br /> -. y 1Aia PNsStd 7iisrl" aMa�d►dolow <br /> . Y Q <br /> - .i <br />(. .f3FIGE t � <br /> {fprWan-Tran WE <br /> ENVIRONMENTAL 1981 <br /> t ofin�tEt INTAW:U ►TEy 11 ilT9 QtlAiITx <br /> Application Is hereby madeiothe San,oacl Local Hsa}th0Wtrlct1o_"k4*ermitt0cpnst em described.This application is <br /> made in compiiar►I;e tt J, Olxt ancetial Halx District. <br /> ,. . <br /> w� .. - � <br /> �t <br /> r Exact Site Addrett5i, <br /> Overs-l8tna 01; ` . .r. Phofle A <br /> F Contractors Name ti 'fl <br /> Contractors.Address ' ;V` Ei4e4rl cy Phone <br /> Is Certificate of Worklttart's Compensation inslsrare cm File With SJ#kIi?? : Yes <br /> File <br /> TYPE QF YIORK (Cklfty_ NEW WELL L� �DEEPEWC3 RECONDITiONF�TFtiI #t3N� �' <br /> Wf=LI. GHLORINATi N WELL;;ASANDONMENT ❑� QTHER II' PUMP 1 �ALi�1TiI�A , 4FAIRQ <br /> REPLACEMENT P <br /> ®ISfiANCE'TO NEAREST: Septic Tank Sowgr Lines Pit Privy <br /> Field Cos <br /> �e <br /> Disposal- � spool�Seepage Pit 1 ,. Ottler <br /> Property tide Private DdIriestic Well Public Domesfic Weil <br /> I[lTE <br /> in IN1"`U�4I }` 3"�i4I31 E TOOK pia,cif Weticcavatlon i " <br /> PRATE � Q�IILI.ED Dia.of 1i�eI1 Casrng <br /> 3MEws iGlPF uG Gauge of C44ft <br /> i4TION GRAYELYFACK Depth of gout Seal <br /> ISATHODiC PROTECTION ROTARY Type of Grout 3 <br /> Ap DISPOSAL 0 6 ER Other Information <br /> GEOPHYSICAL vh` Surface' installed By: <br /> PJ#A1?iNSTAk�tlhkr �. contractor <br /> :" <br /> jYpe,of Pump <br /> lati REEMENT: Ers <br /> ta€e Work•Done <br /> Jf118+14�It+AfR•r State Work Done - <br /> 1 STpUCTtOf�l,lw WELL `WeH biarneter ApPf$ ale.Depth <br /> E ` Psperib8 KAaterial,IIId Prod"ure <br /> p i hereto eertlfy that 1 have prepared this appiicatiori slid that the work will be-done in accordance atitl+Sdn Cocitsty _R <br /> 1fi�tn`ceS,state laws.and it s and regulations©#,t e,5aln-Jw ggWLocal Heal#h Districf. <br /> !#a <br /> ADI, iii Certtites!ht g:"I fy that in the perfo mans t� rk for*hjchojs pitrmit <br /> t, not empftr arr_person in such becomasubject to vrorkman's C sallDr118wsfalif '� <br /> i`:an Nil e#or'a lag ar sc nt g ai ature rttffsa tAe <br /> folk te►fiy: erEifY tfsat irtthoperfoft nce of the wo#k for wfi�i h the` <br /> tars lljy: -"ons sublgct to wo n' ompet sa on Taays of Catlfornia ' <br /> , <br /> € . _ <br /> x,. tD€ew Piei ?lan on Reverse =& w <br /> 7777 <br /> FITMENT t 'ifs Q! y <br /> '- <br /> � {._ed]By <br /> ti <br /> 'Nate-. <br /> ntq�y y P f <br /> > <br /> 5'r- <br /> -311 r e is r:w Cl 'ER CWT �1 PE {�6uC1 r- `Q Jantiafy I&R 3T€ J 8-Received By duty 31 <br /> PATE, it�Ml[TED <br /> FEE <br /> 1OTHER <br /> OTHER <br /> s \ t x <br /> Received by Date;'. Reesi¢I Nas =p tom. $' to _ 1i4-D& <br /> APPLICANT—RETURN ALLCOPWVQ;, ENVIRONMENTAL Mi1ALTit iR1tICE X61 t E TOIa 1�E,FRO.Box apo StOGCT01/, 1 <br /> t <br />