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W x 1 APpgcae 130 ProNssad When Submitted Property CompNtM to To Sign The ApplkMkrt. <br /> A.t Yn,, r� FOR OFVIC�USE I APPLICA.TIC`Pd <br /> `. M�--It <br /> n✓�.: (For NTra^slsrsba,AndIva6M,Suspendoble) PVMPwELt. .. <br /> ' <br /> E141F1BA0�4A?E9d7Al 69FAL4FI PEAIb017 ��..[ <br /> � (COMPLET3IN TRIPLICATE) OrPAnS6$EDA4JP' <br /> ac f `4 Applicatlon is horabvmadoto the San Joe uin Local Health District fore <br /> pemitto COn9rNC10ntl/Orinstall the work.heroin d(airibed Thi, "8'w' nd � <br /> .�.. c <br /> /i made In Cemplianee rh San JD in County O inanca No.1862 anC the I arM "n Ell <br /> S � L H / reyulatlo it of the San J 1 Desi -_- �._ <br /> Exsct91.s Address_ 17t�y. Ciry/1'own <br /> Ownmr'e Namur&2i. n�t �.ev ^� �f t��t ._Ftrone <br /> Address_��� v u__.. City _ ) <br /> C.';Tt j.:toes Noe�.®� _ Lice rseQ�{ �`j BUPh6ro_, <br /> 3� <br /> �'•,, Grnxactoem AeBrea �,.�s R�r G�s�G.• 6^+romrxy Phone <br /> Is Cmrtlfk.:+.d Workman's Coripenaatlon Insurance on File With SJLHD? Yos C.—" No +I'r <br /> T"Off Ill(CHECK): NEW WELL&" DEEPEN❑ RECONDITION-0 DESTRUCTIONO <br /> ,. ' YELL ChLORIIIATdON❑ WELL ABANDONMENT El OTHER ❑ PUMP INSTALL IT!,JNM-"4lUMPREPAIR❑ xir, <br /> a OjS(ANCS i0 NEBREST: Septic Tanis _ �L� Sewer Lines _ Pit Priv, <br /> Smwego Disposal Fleld .i .Caaspool/Seepage Pit_ Omer Ee�d d i <br /> ��'? ' Property Linstl <br /> L1,10— Privets Domec'.Vell Public Domesttrr.Well <br /> g <br /> xk3�r 6F37'y?BG UBE TYPE OF WELL ,er -•� 4 <br /> w� D I".'DUSTRIAL ❑ (,ABLE TOOL Dia.of Wall Excevmion_ <br /> 'un ESTICYPRIVATE ❑ DRILLED Dim.of Well Casing_1:9- tl <br /> ® OOMESTK;/PUSLIC ❑ DRIVEN Gauge of Casing <br /> Lo IRRICATr.'d 13 GRAVEL PACK Depth of Grout Seal,. _ ' S <br /> +� CATHODIC PROTECTION NARY Type of Grout C1 -,sz Iili <br /> I�"': S Q OISPOSeki- ❑ CTHER Other Informmlon C ,> <br /> Q GEOPHYSICAL — Surface Seel Installed y. 's _ai <br /> +.x ?� PUW Na-iALLATZOM C britractor <br /> _ Type of Pump H.P. <br /> t+y, rA,"SP Rsin-4c.'-m T. DSMo Work Done <br /> r%;;-n q;17P!r- State Work Dom <br /> "/C^`u '=f D.,oan Cri mil Cr l�Ru: 'We:]Diameter - _ Approximate Depth. <br /> " - Describe Material and Procedure <br /> - —' - <br /> I hereby orf fy-Rat I have prepared n1a application and that the work will be dohs in accordance with San Joexi County <br /> ,. o,dinanc tn:a laws,and ru"and regulations of no&in Jeaouln Local Heshll Dlstnct -. <br /> ,.; Homno Or wErx,^Md e35nrs c5ynchr CO&W.ca Iiia te'i'x-tnS:"I UMify that in the performance ofthewark for whichthlspenn?t +.,s <br /> '} YR ia^�1Ctl,i G1t+L7 net employ Gm/(.4 rter1 In aDCh R18fe:tef as l0 txxceme SU%finet f0 WOrkR1811 S compenaaliOn Iavrsa'Caeian{a,' -. 5,. <br /> ' Cortbcclaes h':;IRS er usb-cimtFeN..Ye aiygnti-x-e con es&ho fcs?ocrlag:"I certify that in the pertornerce of tho weds forwhIch this <br /> ,1 permit is+ a:ed,I sha(i emplm/porscns subject to woArrai s cempensation laws of California." <br /> a R <br /> IxV far ear 8r-;iee:en Pr"gr to Orovt''mJ and a enrol kts;+edtxn. i n <br /> 42 .,�.c -� f1't � luThIma DMK�— <br /> <. <br /> eau Pio:Plan on fiaverws Side) � t <br /> io <br /> k t ^'l FOR DEPARTMENT USE ONLY <br /> FMIASE 1 - - <br /> t } <br /> 4idica2lon 4ccvf#ed By <br /> AddiakmN Grnmicres: - <br /> '�2I¢e,%sst:on Ill livpme6gt " <br /> px roe y Dave_S—l(l—�/ <br /> Inspection By Date_ � <br /> , ,ImV=:13 ANNUALLY ❑PER UNIT E3 PER Si;E ❑ EACY ❑ J..sr,t a Ri,,i a ey January at 13 jury r a Mecmfuem ey awy a <br /> REAOT <br /> +Yg RAST E%PLANATiDR� B�raM. REMDATEE REIAITTED AMOUNT OIIE (aeacrean <br /> v'.7' a�7 ALexMT i` i <br /> 1 d <br /> LESS <br /> T1d1 <br /> PEWALTY <br /> OTHER -- <br /> Meares q QDN R9CNpt rb. Pw n No.. .- .. lairrca r]ab W Ilan. DNhwem <br /> .t._ ... .iA/KC/My-I�n111M AL1 ee?8f TO: UIYa405GffiAJITAL OfAIYN tmiMaTAart»Caf .... . taM E'HAMTM Ala.r,0.mss <br />