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IAM <br /> ESL PER " APPLI IT {}JV= O� � UST 1V w <br /> -=; - <br /> : SAN_JOAtUiN_COUNTY PUBLIC HEAlrTH_SERVICES <br /> ENVIRONMENTAUHEALTH-DIVISION_(PHS EHD) <br /> 304 E.-UVeber, Third Fl�or,.StaciCton;CA- 95202 <br /> - . <br /> (209)`468-3449 <br /> x NON REFUND BLE PERMlIY E?(PtRES 1 YEAR FROM DATE ISSUED: <br /> Application Is hereby made tc 5an;loaRum Gvunty"far a AerrnR to construct sridlor install.the wcrk:dssetibod, This applicaw- s made in ecrYiplEanog Yiitti` <br /> Y San Jcaqufn Cvuriy rQFe"ve!oprrren/t}Trle, Chaptsr 9=1"17 5 3 antl tie St^ndard&pf$s17 Joaquin County PUblic-Health Sen icas;E,vironrienta!stealth Div; <br /> ;,flr,, <br /> WELL Location=�F U�f'. �1 63CkQw1 Crass Strut Fr£iNUOrIL� Asse sor s <br /> _ - Clty:S.i� zip 9 570�",Parcel#. <br /> PROPERTY Onmer r r. V�l�•CiiJut l4►w,'wq - <br /> ress ` b N C,ty S t;1C •+ :zEa QS7.;;5 Phot. `t4 3 �,�Sr <br /> C'i7 Conuactar_ rAddrasa �' r1 � . f _....�ziP. Cic ?Pl;one <br /> -- <br /> TConWtant,Sun Contrecigr"7t►t- Y3'35 �q Address �(.�rAl. ds,� _ - " T <br /> �id# -_ Phon4#V`t <br /> GIS Coordinates:X <br /> _ Y <br /> ToWnshlp Rarige <br /> 777t77Section <br /> WORK=TO-BE-PERFGRME0 <br /> (NEW WE1 BORIkG"(CPT GEOPRGBE �HYQR t1NCH HAND-AUGER'OTHER-) �DE5TI�UCTlON <br /> � (choose-yoe telow) <br /> BCRtNG� - ,- - - - - _- <br /> r €ER- ORE <br /> "Cther =.-_ LL# - - .`Q PRESSURE G3RQLT =: <br /> INSYA LLATlphl TYPE- -CONSTRUCTION SPECIF1CA7tON5 =- <br /> 47OWTORING"T FtQLLCW STEM rJtA OF"'EOREHdLE `�' IfAULTiPr_£CASiivGS (j:rES Vp ircrELL CASIigG DrA: <br /> - �r <br /> QI � 1 : AIRw . <br /> STEEL`_, JC,- �TYPE CFCASING - <br /> -©V4POR MU(7 ROTARY <br /> 0 AIR SP—_RRGc - jl - <br /> - DeGF GCUT°= A ` -e TREMiE YYr E7 <br /> PUSH POINT—. GROt17 SEAL`-PUMPSM {NOTA: MAXIMUM <br /> M6E�-URSE=Q= FlAL UGd-E-�P5 TF= iJS>ar3s0t,�--;= " <br /> -- - <br /> ©�Oil�£ORIhG'- Q HAND-AUGER <br /> A <br /> .PPR_OX _ 1 �SOLTED TRAFFC SGX cir j 5T. <br /> t <br /> ONOUCTORCASINGQOTHEi Rloc-. <br /> PROP0SE0? YES, Ilsi specihcat:ons hPte). <br /> COAAMENTS. <br /> QF. S(TEBO.RINGSTREQU.IREACCESS-QRTEf_C�t_O,?iCHNiEfT-PERMITS= <br /> f heret y cert�y.that�l-have-prepared=this application and-that xili oe:dcrse it"accarclance witrt_Sdn Joaquin-County Ordinances State Laves and Rales ..:s: <br /> and Regutations"af tRe Ser,,.Jcaduin-County Hortmaoti+iner pr license aycnt's signaturs" ertifles;tie.dlowirig: "I certify-that 1n-the.perfosmance-of the work.'.. <br /> +ar whteh"shin pesrnrl rs fssued,Tl shall riot eiri}�lay p�rsans svkjvC2;v VY4R/CERS;COMPENSA 11pN i dsys of Gadifcrnia: Contrac'or'S +iii eg cr suh <br /> contracting signature cekffies the fol!cYV-"§ 't crr'fv that r t ha:parformance of the wank for ahicl;this petmtt, :ssuetl l he!!amploy parsons sir;�Ject to <br /> fI <br /> ORK�RS'COMPENSA;lON Laws of C&irfomfa <br /> THS APPI:! NT_mU T,: � 48 WORKING-MRS IN AOVANCt PC}R ALR RtC3Lt€IwED IN$PE TIONS. <br /> _ - <br /> $Egneo X - Title- - '� 3 <br /> �.•, \r?� - Date <br /> 7_SEE SITE -MAP=ii1! UGIT IV_ WORK PLAN DATED <br /> DEPARTMENT USE ONLY. <br /> ­-1-Application cation Acceptec By - _ Date issu®d- � _ Area <br /> Grout inspection By __F <br /> ' Q� <br /> t)�ct uctior-Inspection try -hate - <br /> _ - <br /> F.�t <br /> - - <br /> -_COMIII14ENT51 CONDlT10N5. - <br /> -ACCOUNTING ONLY. AEI b <br /> LL - - <br /> T <br /> _ - - <br /> ;. r . .. <br /> P.ECQOES= FEE_fNFO '.AMpUtV7R><RniTTEp_' CHECK# _. ..- REC08Y :URrE'- �1i2awrT15ERVICE�tEQUESTP! INVOICE <br /> LIM <br /> C� IIZ ACTttvUaIS" i-GhISENE C7LICENS - DECkR-ArI0N <br /> .: . � - �ES �ON�EVATJ�" I <br /> 27*UNIT 5/2�I9s/s;gn bkpg/Ml - <br /> _ <br /> Y <br />