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_ -- .. -- -- - APPUGTION FOR WELL)PUMP PERIST <br /> SAN„DAQUTAI CatTlffM PUBLIC HMTH SER=29 <br /> EMSONMEIITAL HEALTH WMIOH <br /> P 3 SaX 358. 445 11 SAN JOA(WIN ST, 3MCYTDII.CA 962OI= <br /> OM 3683420 <br /> Nt3N.�ONDA3i PERyR �3 1 4F_ll F➢011 SATE i441IE0 <br /> xmmMm a Tripicsi <br /> AwLication is here by pude to the San Joagain czrty `or a pereic to comtrvct and/or imtaLL the wort described. Thio sOPti"tion is <br /> a- in compliance with San J oaau in Cm inty D eve t oomen r T l t l e r CSapter 9,-11T5.3 and the Standards of San Joa4n n county Ptal i c Health <br /> Services, ETrvironrnental WaaIIA L Oo T- S, Xftl Av'- <br /> ,lap AdCtre=./or APt+>ti TRACY R AEL ACRD A+ 1l+k +rnCAiZ1hUz Cl ty TR Pt c—Y Parent SI:eJAP%X <br /> dr,er's Mane SOUTH E N - c=FEC Acr+sess N M 2K6 PLAZA SF. C4 <br /> At <br /> cent rar_nr <br /> INUu6TIL7=A[- Co^,P�,LRNCF_ aac--ss Q83$ 0/d Pl4ce-v,'l�� �c�CS �zphone #((?16 369-,�97/ <br /> T 4CrCa Y37 <br /> suo ;axracior V v t�aMF�,T Aa�rss /iZO� Ey7ULk Avg, _ Lj=r 95 3 3810 mm e $ C9/G066 <br /> � mr. <br /> TTP; OF tiELL.'PlJ"Pt L XY=*-- Z /rs�tCEIgEXT HELL xAMI-MING LEiL 3 Z1�R, QTIIE2 p / <br /> I7 aff-OF-SERVICE ALL ❑ acOPMTSICAL LcLL it ,SOIL MIRING 5011 bo"Pfl -S <br /> EJ INSTALLATION ❑ -JiL 57S E't PAIR C CWSS-C0"zCT .REPAIR 0 VAPOR aTRACTiOY iTLL y <br /> LI New ❑ b!pair H.P. DOITH P6M4 SET FT. FIRST WATEt LZIJEL N <br /> (TTPE OF PV!' ) <br /> 11TE)<DEa USE TiK IF WELL CDNSTR9 ON SPEC:ICA <br /> ❑ ImuSTRIAL ❑ OPEN 9UTTCK DLA. OF WELL -fUVATIOM /� DIA. OF MaDUCfM US;MG <br /> ❑ GCIESTIC/PRIVATE GRAVEL PACY./SIZE �1 C nPE OF ZASIWG/STa:./PVL PV C- DIA_ OF WELL CUING YI/ <br /> ❑ PUBLiC/WNICIPAL ❑ DRIVEN /&nferey CEPTB OF CtCUT SEAL beef SPEG;FICATION 1 ea4 a went 4. ,I% i�ien?arw�C <br /> ❑ L�IGITICM/AG ❑ OCHER ,�tnet / GRCUf Sm IMSTALLE7 3Y =Lrr BRAJO yA4El..Qt1E5-r V- C <br /> MIA[TTORIYL GACUT SEAL PUMPED: � <br /> iPPitGY.DEPT1! Tes [3No COMCRIE E PEDESTAL ay DRILLEZ: LI fes <br /> 2!s ��( I0.rK:IfG Ct£STE4 BmfmvE PIPE IOLk i n� ?,dX <br /> PRaP4SM t0N9TRUi TWWDRILL= NIETH02: AaID ROTARY_AIR RQTA;ZY_ ALIGcR2L CABLE, DTxER, <br /> ( tiereCy certify that I have 7,e0=raa this application and chat the worK wilt be dory in ac:cordance with San Joecluln county Cminamms. <br /> Star_ Lars, mid Rules and Ragulationc of the san Jesauin County, Home Owner or Lieemed agent's cignture certifies to folloring: <br /> LlCitIQUWI'S <br /> that in the peornance of r'r tar which this perwrit is issued, I Shat( not asnLOY perscm 44abiect to in ria perfrasnae C�cr=mce <br /> Laws c-f California.• Cantrac:or's hiring orr0 wosfi <br /> n-centrac:ing signelre certifies the followma: I crrtiify that <br /> Of ti, cork for ,-trh 'his permit ;- issued, I s`.:ll aWtoy person,- subject to 6URaK"'S C1MF£MSATION Laws a California." THEAP>•L=0 <br /> musT GAIL 24 P-nRY IN ADVANCE Paa'ALL KNIRED 21AE3: x3 AT CAU 4&&,3;Z3. Caavlets drawing a* Lower .arca provided. <br /> �Q}y lJ �E�I�cJA3L 1�/G2/iGTo� Date'31 <br /> signed x _ <br /> Title- <br /> i <br /> OEPARTi[EYT OSE•NL7 <br /> App(icatian Accepted 3y C'� Dau C <br /> Ptsp Insxction By Date <br /> trout Inspection Bymmm <br /> Destruct-ten trasc•c=ion gY_ �l ��.- Date <br /> A=UXTDiY per: AIDC <br /> FACE <br /> pE COUES FEE INFO AMWft UEMMU MIE=MS1t AfCEIVO IT DATE iERA1TTllER1iIL�RCBtiEiT ftIX= WICF <br /> Z o �9• D/77- 1 & z-- <br /> i I <br /> I i <br /> O D <br /> F-0'd 02_869'2-9LS L 01 WOdd Wc&7:23 t-EZT-bZ-O T <br />