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a)'zi 79101 <br /> - — -- — - APPUCATIQN Fal WELUMM?PERRU I <br /> SAI! MAaUlM COUNTY PUBLIC itMTH SFiV= <br /> ERVIMMMENTAL HEALTH 0=10M <br /> P a SOX 3M 345 N.SAN JOAGUIN ST STOC><TDR.CA *201-M <br /> MM 4694420 <br /> ibLMMICA 1 PEWR`fig 1 7E!!J<FRITNI DATE MUM <br /> CAwolas in Tnip z@W <br /> AWiication is here a/ aside to -he San Joaquin Cz rtY `=r a Permit to construct and/or install the wort de= ibed. This ami;czrion is <br /> wake in cmtiwice with San Joaquin Ceunty DevetoLsent Title, Mapter 9-11T5.3 and the Standards of San Joaquin Country PtrAic Health <br /> Services, Elivirotyaentat kaalth Division. 24 <br /> Joo A�ssesslor AP"- <br /> TR fI L Y RAT L �F3 2 T> G ty TYG C u Pou, t SI WAPICS <br /> �viS)Sv!—l7e, <br /> 064W'S Name ✓ u <br /> Phone 3T <br /> � �-!uo Ie�53 <br /> C.3ntra=or _L, r%as�r,'ct� rnnl,`cr>,t� Jaz-ass �- 983& C 0/N'(��✓1'llt: e 7J7 5- Phone q//) � 71 <br /> �� •� Sac rli vrie.i-to 'fI. 9S8Z7 �} / l <br /> Sim arrtrxLor/(4 LimPhone $(/C�IcEZ-Z�2 <br /> J <br /> TTPE LFLL.'mJwP! rl X"WELL ❑ t---AMkT WWLL A u anmR <br /> afST3tl1C710M ❑ CLa-oF-SERVIIZ WELL ❑ GEOPHYSICAL :Ef l ! ❑ SOIL DCRING <br /> Q INSTALLATION ❑ 'AlL SYSTEM YFPAIR C CROSS-C3"WCT REPAIR D VAPOR EXTRACTION :TELL >t <br /> ❑ Yew ❑ Reasir H.P. DEPTH P64 SET FT. F-IST WtTE3 LE'/EL <br /> (TTP£ OF PVW) <br /> INTMF0 use =IF WFU CONSTROCTIOX srt ZFICATlM <br /> iI IupUSTRLAI. ❑ OPE4 WTTCN 'DIA. OF WELL EXCAVATION DIA. OF Cf)YDUCTCR CAS:)tG <br /> ❑ DCIES:ICJMlVATEGRAVEL PACC13= 1� TYPE OF : rwrwSTE>:;-P c ✓C DIA. OF WELL CUING <br /> Q Pu3LiCflgXICIPAL ❑ DRIVEN i � CEPTA OF GROUT SEAL SPEG:FICAT ION <br /> [3MIGITICH/AG 17 07HER SCi r of GROUT SEAL INSTALLEI Sy ND SRANA+Ne`��n PS�<I/ rn <br /> ❑ Wal I ING GROUT SEAL P mm: �(Yes ❑ Yo =RCSZM PEDESTAL aY DRILLER: Q Yes u 40 <br /> APMY.DIM Lccx:)Ia CHESTER am/STOVE PIPE <br /> PQDPSlM CONSTRUCTIOiiIIRIUAG KETHa2: MM MARY_AIR ROTARY, AUGa UBLi,Q7It£R, li <br /> I ier oy certify that I have PeParad this apeiieat:an and that he work rill be done in a�r+ce with Sen Joaquin County Csclinancrs, <br /> State Lars, mrd Rut- and Aegutatienr of the San seaquin Canty. Huse owner or Licensed agent's signature certifies the following: "I <br /> =r-ify that in tha per*onmaixe of the wort for icy this permit is issued, I shall not nipLay Persons subject tar 60boAN'S C01WENSATIM <br /> Laws cf California.• Contractor's hiring or s,n-ccntrscting Sigrrt-Jre certifies "o following: " I certiHy that in a performance <br /> of the uw-k for Which :his permit iS issued, I ShItl enptoy persons subject to uORiO"/S COIGIRSATION Laws of Catifomia." THF APPLICma <br /> WU3T UU 24-itnll"ADVAYCF FOA ALL AE0I11°30 qW=KS AT aft 46331I33. Com ets drawing at lower area provided_ <br /> '� / <br /> Signed X / ��- -_— '�, }•J-`''L� i i t i e <br /> k I I <br /> I lil i ! iI <br /> B>B'ARTKtwal ank Onyx <br /> Application Arraoted 3y <br /> Grwt Inspection ey Date P%W Inzoec/tiion ZN Date <br /> oest:=non InSWtion By Date Car>erts: , IN12/ �C� <br /> Al:LallsTai 0>fl'!~ AIDS FAC? 7i � <br /> r <br /> PE COUES FEE INFO ANIOW MUMID I CHEMSIMMA AEMYED BATE PMMIUMICE WMS.T �YaiCF <br /> 0 0. !oa Dl !t r 4 s 3 <br /> � I I <br /> ! k <br /> ZO'd 01.r-,BG9C9161 01 W0U Wd617:00 t?661-bZ-OT <br />