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- -A??UI;A11UY rUH RLAJirvmr re mcc � <br /> S;&aUTA COUNTY plsLM HEALTH SERVICES - • <br /> YIRBNMENTALHFALTH BIOCC,O r� �'� <br /> STBCXTBH. CA oZBI388 '\J'\/`/\/'/\' <br /> F. W a lel <br /> %am. ffUNUAets E�RE4 R FROM UATF UT=60AN0Wbb . <br /> 'ar a rnit '.oi cioen�t rd/or imzzatL -he work �eribed. This application is <br /> +cp(iocC is here Dy sada n Lha San Joaci.0 Canty tx <br /> wde in caaol fence with San Joe•vin Caanty Oeve'-w++s+t iicl^, Chapter 9-1115.3 a*+d the S:aM.ar<s of San Joaquin CoLsILY P"o(ic Ankh 2 <br /> "ervices, S3rvirotssnta( Health Divisirn. M /Dz� '/��� 13 <br /> ,ob Addresslor APR SdM PAf'TFT(' AVPn11p City Sto—cktori Hartel si zelAPA% ` �i JJJ <br /> YYf'9 YiY <br /> Montgomery Ward Atdrtss 54 )0 Pacific Avenue phone s714/7736227 <br /> Cx+tracmr <br /> Environmental Audit, ;&g,= 1000A Ortega Way L;d 606348 Phox .1714/632-8521 <br /> �u Cancnror <br /> V & yQ Drillin4 AddreS= Monier Park Place Lit_' 720904 phone t 707/374-281 5 <br /> Pic viqta CIA <br /> j Y9e OF YELL/P4wPs REV LELL ❑ REaLCN <br /> ACZ4EHT LELL ,J NiTCRING YELLS ❑ OTHER <br /> ❑ DESTRUCTION ❑ OJT-of-SERVICE DELL ❑ GECPNTSICAL WELL 9 '❑ SOIL BCRI%G <br /> INSTALLATION ❑ L ' SYSTEM REPAIR ❑ GOBS-ccNXECT REPAIR VApCR E(TRACTION '.21-1 - IlFT"T-6 <br /> Now ❑ Repair N.P. <br /> DEPTH KW STY IT. FIRST w;aR LVEL to VEW-1 3 <br /> ❑ . <br /> f:TTP- OF PMIMD) <br /> UFTEYOED USE TTPf Of WELL COMSTRUCTIOR SPfCFiC1710N5 <br /> INDUSTRIAL ❑ CF-4 eOTTCX ULA. OF LELL IXGVATi011 <br /> 10.1 <br /> DiA_ OF CUCUCOR GSING <br /> ❑ UCAESTIC/PRIVATE , GRAVEL PACIffi__ Tc <br /> SYPE OF CISING/STL/PVC PVC DU. OF WELL CASING 1 "/211 <br /> IPAL ❑ DRIVEL OEPTH OF GROUT SEAL 10-5571 4-2 SP=_nFIC&TICU <br /> G E6 OTHER GROUT SEAL INSTALLED 9T GROUT BRAND NAME <br /> L GROUT SEAL FIAMPFD: es W C=900E PEDESTAL <br /> HCNI70RING <br /> BY ORILLERs es G Na <br /> APP4DX.DEP'i ii 60 LOC:HG CHEST.R ¢0%/S�OVE PIPE <br /> PROPOSED C3NS7RUClONIBRU.lilL6 l�HOO: MLD RGTAiTJ AIR ROTARY_ AUG'<R. X CABL' OTNE2_ <br /> ( eererry <artifY mac L have prepared a¢ti raarn and LhaL the work vi LL of done in ac�rearce vi th San Jaagtin Canty G_iruret3, <br /> State Laws, and RUL ea and ReSul atf era Of Me SYt Joawin OOMnCy Hoa+e owner or Lice -ad agenC's s =tb««ts XRV_AW,Ses the foL�AGTIa_ <br /> certify that in the p arforaanee of Lhe work for�nich :his perait iz issued. I shall <br /> not emloy pass <br /> taws of California—' Caneraror's hiring or z;:-crncacting signature e_rti£ies the followings " I certify -hat in the perT. —m a <br /> SF the _ark for which this Fer.Oit is issced, 1 chap emolcy penans s1:Ciect to '-:RXHA%'S CCwREBSAT ICP Laos o? Gli'.orni a." TAE APPUC%T' <br /> MUST CALL 24 UFd IN AOYAX=;e*-k1rMQU1WI EC IDMS AT aD91 4M34'27. C=Lece drawing at louer area/provided. L q <br /> 1/af • I)_ 7ir ,�l(() 'foie Cr4> � DaceJ�f( <br /> SigneC X <br /> Lllillll I II I I III I <br /> ' I 1111111 I I I 1111111 <br /> IlilVlllllli 1111111 IIIlilil � <br /> DPART11Fti USE UNIT <br /> Oat <br /> Aepl icaci on Accepted Sy <br /> Date <br /> GrauL Irspee:ion BY <br /> Oate Ruso En _:i <br /> Destruction Irspeet-cn Sy Oace Crna+encs: QW <br /> ACQUIFTBl6 ONLP - AIDs FACS <br /> PF =13ES I FEE INFO AMUUYT REND TO I CHE=r%SH RECEIVED DY DA I PSMTTISERVICZ REDUEST NUMBER I INVOICE <br /> I I I 1 <br /> I I I i <br /> I i <br />