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<br /> 1 AMYLICAItUX FUR VVELLIFUMP PERMIT - •- _»_.
<br /> SAN JOAQU[N COUNTY PUBUC HEALTH SERVICES
<br /> i' ENVIRONMENTAL HEALTH DIVISION `
<br /> i P U BOX 268,446 N.S'AN JOAQUIN ST.,STOCK-rum,CA 9620i48H
<br /> (ZOO)468.3420
<br /> i �' j , ROR•R UN AIME KNIT FXMREE f A FROM D ISSU 0
<br /> •i ICee,Nleta Fo Ttigrxatel
<br /> ApoticatioA:ts Afire byrsyde to the son Joaquin County for•Permit to esrlstruet
<br /> ^o4e''in,conpli a yith, aA Jb and/or Fnstelt the work described. ihia o'
<br /> Servibes,
<br /> fmhr S nagNin qty Oevelotrvcnt Title, Chapter 9.1775.3 and the Standards of s PPTicetian .s
<br /> o�n�iLa halt Oivieiort. h on Jb iq
<br /> equ Cotnty hbtic Nesles
<br /> •�.Job'Aedr�rts/or•:Ais1Ji •�'3$`��'/,,' C(s7v� _ ,;. ,
<br /> ..i- .• , ry.._, r_�City G`' ►arcei 4 se APxA i 21 Y•'Jl3a-
<br /> =tRat'ec"l.Nais!')Nl l •' :�b`tir.l'�_ �01`t+tnfs n�tddresF I�Z C� a�r r v )r r Y Z
<br /> .'Controet)rte. �.,J
<br /> A 1 ►�C�:.7�fk1KC.l %++� ' _�Addraad !
<br /> 444 Vo ��' + .
<br /> : Sub,Conttacioi ' i i' Y Bic�- Pha!e 4 Sin 83 -7Zf
<br /> ! - Address O {a r,..•..d t,
<br /> ' �f: ,.!. •.. CicII 67T pyopp•g�goO� ZO�02i
<br /> :TYPE tis -
<br /> Wftl p REPLACEMENT WELL r
<br /> ' -( 1% •. U N"ITURIRO WELL JT ,y
<br /> MAW tug:%% [I:OUT-OF• ERVICE'WELL �- •'(7 umbt- '
<br /> �I! { t) GEOPRYSICAI VEIL/ i
<br /> •. t .t! [>j,RNSTAtdAt10N••• •tl YELL SYSTEM REPAIR q IL goel"C'
<br /> CROSSCONNECT REPAIR - '
<br /> Repolr N.P. T7 VAPJtt EXTRACTION WEII t'
<br /> (tYPf OF:ifJftP) I: � ���p � _ DEPTR PtW SET F7,' i'IR57 i1AitR LEtEL
<br /> :1 . D'USE' i; ';:,•TyTEiOF YYEIL •. ;.Cpt(SYRUCftDN SPEl1FlCATtONE •
<br /> �•h INDUSTRIA: li•'• L•.1 ,:• . -: I
<br /> '•I+,;,[):: �N DOTTOR ' DIA, OF WELL EXCAPATIOR DIA Of fOltOttt iAt CASTNG '
<br /> ;Tl.D[StE3ftt%vi[fYAIE•'L)I�.Aiia;PACK/SIZf TYPE OF CASIRG/$TEEI/P1rC
<br /> 01�.OF WLL CASfMC .
<br /> 'TI tUDhlb/NUyJC[Y(tl;.qj D LtfEN. , CLEFT"OF r,RCUT.S AL
<br /> srec•1FlcAtION ; -
<br /> i,[J IRAIGATIQW/AyII, HE1t; CRDUT SEAL INSTALLED BY
<br /> -.:tl i)al.lrwtrir i' ----. talbok-Sk"O MAKE r
<br /> i;, GROUT SEAL KKPED: a Yes
<br /> [T NO COMCRETE;PEDESTAL RY uiu, ER:
<br /> 'APPFOXJDTP(il' I!•a 'I:.1+ [I Yes fT'Ro
<br /> • LtKXING C11EST[R BOX/STOVE PIPE_
<br /> PROPOiFo_Co71STRUFTtt1RIG.Ll►1c MEMO. KUp ROTARY_AIR.ROTARY.`AUCER�CAsIE,,_OTNEI�
<br /> hgrebylurci•f,Y jth"Jj)i vt Prepared Chia epptication and that the work xill be 0one � �"'�-'-'•
<br /> rtrt etcordeice with Ssn,Joequ�n County OrQinances,
<br /> .'Ttitd lrya,;oiwf; ytea.and Re.Oia],atiprs o6 the San Joaquin County, Nome owner or IIcsnsed eecntrs Yiyrpettw•e eerLFfe.Ksl thq totlowinlJ: ^t
<br /> iAalye�f(erfo e:df.:fljq work,ft,¢wt1+Sh this perinit Ts 5ssuad, t shall not
<br /> til./'f'�riias•-_"C eaefars lllcinq or�sutrcontrect:inq siynaturc certifiec;the fowl lovin oy "ons DJOct to.'NORptRp+S COMPENSATION
<br /> [of theviiork:f •t rs t Fsiss.a I hall ql.'p I'certliy tMt Fri.the performance
<br /> y persona t4bject to SARXMAN•S COMPENSATION Wtrs of{al�forpia:w TREJtPPIICART',
<br /> U Vll TO ll:A IR FIC l0 T U9111-1E8•li2J. Coatllete drawing at Code[areb/'TProSidtd, .
<br /> Tiile'�7 .r �� ►✓+ Datc r4 g
<br /> r ....-_r._.�-
<br /> i: rCQT rIAN (cram to SCOtc) Scott--I to
<br /> ' .l; :'•I"a •: �� ..
<br /> •:'t.:jNOmei qf.�.crects,v.R•+7o a:neeript.t0 jr:bourdt the'proPerty, �� - -
<br /> ^. •... ny location of bo7rse eexatre d1i•
<br /> 2. ^OutirnC of tljC;pro{ler 1+.givii+q:.idhlmslons ond=Jlorth direction. lbssl sYsts ei
<br /> 3 •:DiM,6si proposed:*xpahesoft of Fexagr,alspoaat•systv".-
<br /> j- g1r1d'oucii =: � •focO.tion Of•alt,exlst[no and*oposed• �S. locotionof netts MITAfes red�w:•.of�1S0 (t. on
<br /> etrt,civizs.,"i�elul iia cwered.'>rceis-ouch iss.pattos, drivtnro
<br /> :and Sal:ksi i•s 1- Ys. ` the Property or•adjol'nlgq properly.:
<br /> c r4
<br /> I fI t a ��'.r1e'.r
<br /> xl
<br /> 3✓�
<br /> -:•A: .�.r';,.i' II :• aid.:'. '' �_ - J, ` -
<br /> ,rDEPARTMERT DS[ONLY ••!t'' -
<br /> ,.APPlictt.wti:AccY tYd`[� �g1 •= .
<br /> {. -, >�f ; i::: I•..,• tiatl`J Ares -
<br /> -:•LraVt. -ion -
<br /> i Date Pump inspection Dy
<br /> Eio*itrut{oiiilnspitcipril8y Dato C I
<br /> •, ,1 ,
<br /> '•,"�1000UNTIho:ONIYI ••AIDX''... - FACE! + .f '
<br /> is .Y•- ..r.,• :.: ' '� _..� � � 4 '
<br /> P[.ro�3ES .FEt'i1tFD;':iA{tDURT El[NITTFD'- :GI CASIt AFCEIVED. r DATE rEXpIT13fRt+)tf itfaUfiT'AUM9EA ;IRYDIO�_.:.
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