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APPLICATION FCR UN-3ERGROUN'J =;,.YK R-TROFIT, OR PIP' -NG ZPAIR PERMIT <br />�3IS TERM:: EX?: -RES 90 DAYS F:C'l TFT APPROV;,�- Da.__ DO JOT '.+•i2I:E IJ AN. SHADED AREAS_ INDICATE PERMIT —PE 57t.0' -t: <br />..-A.-`A R_:__OFIT PIPING REPAIR <br />' F -PA SITS 2/1 PROJECT CONTACT t TELEPSC1Tc C <br />c-aCILI: t --Z <br />a ' <br />I ADDRESS / <br />I ' <br />I CROSS STREE-- <br />S ; <br />T J OWNER/OP`_'RA"i OR <br />1 <br />PHONE i _// "I. ,a -'s4f . <br />I <br />PHONEc7z <br />I <br />C courRA�2oR vaME ! J PHONE s _ ` r J <br />r J CONTRACTOR- R S t / J Ca LIC 2 U 1 J Cu's <br />-T I t..J FF' liiLLL�ttt <br />g ( INSURER J WORS_COKP.S /,[% O I <br />C I OTHER INFO. -L AT=ON I J <br />T <br />0 I I PHONE 4 I <br />R <br />1 I PHONE 2 1 <br />�lttil [i li l[![ll!!i![(1311111(t <br />T.l Ic ID B T:,`; SIZECHI?iICALS STORED CURRENTLY/P_FEVIOUSL7 DATE US: INSTALLED � <br />39- f I 1 <br />T I I9- 1 I 1 1 <br />a l 39- 1 I I I <br />Ta ; 29- 1 I I 1 <br />aC J 19- 1 J J <br />I9_ I ! I <br />1 )9- <br />—j 1 1 l <br />1111FIl111111111111111111111111i11f11IIIIIIIIIIIIIIII III1 1111111111If111-I!J_1111111111111111111I11IIIIIitilllt111fIfItt11111� <br />?t1 <br />APPA VtD APPROVED VST7i OY7DI'_TON DISAPPROVED <br />S� AC`RiE-YL TIH CONDITIONS) 1 1 ^ I <br />^ 1 DATE <br />` l if J1 <br />—�i1I1YI IIIflllIIiIillllllII 111 1fill II MIII fI 1111111111 lull IIIIfIfif ULIIiifIInIIII III IIIIt IIiIIII1 IIIIIIIIn III <br />a2?LIC .NT MIS. PERFORM ALL WORX _N ACCCRDANNC= SAN JOAQUIN COQRT O2DItANCES STATE LAWS, AND .TULiS AND 2EbT1I.ATZONS OF 1 <br />5A,K JOAQUIN COUKCY ?UBLIC HEAL --I SZRVICzS. C:.1'=4 OR LICENSED AGOWS SIGXATJR£ C-'�RTIFIES THE FOLLOWING: 'Z C` :FY THAT :.A j <br />pEZFORMANC= OF TYE StORK FOR WHICH THIS PZRAIT 1S ISSUED, I SiJIL NCT EMPLOY ANY PSRSON IN SUCH A :4M7NER AS TO BECOME_ J <br />SUBJECT TO WORiO-- 'S COMPENSATION LAWS OF CBL::--0RNIB_' CONTRACTOR'S HI.Z_VG OR SUBCONTRACTING SIGv;L7URE CERTIFII-- TRE FOLLOS:ZK=J <br />-! CSRT IFY TS;.: I- THE PERFORM;' -VCE OF ':'FIE WGR=: c0R WHICH THIS P IS ISSiIED, SHALL EMPLOY PERSONS SUBJECT 7n `WORICER'S 1 <br />CJISPi.NSA'1-ION :-AWS OF Qf 1 <br />�.?PLT CANT'S SIGNATURE: U, T DA'IE �/ // ez <br />BILLING INFORMATION_ <br />Indicate the responsible party to be billed for additional PHS-E.BD staff time <br />permit payment coverage per tarL�c_ If the party designated below is different <br />applicant, e -q_ property owner, the party must acknowledge this responsibility <br />�v si�I►ature and date below. r <br />S -gnatllre_ <br />expended beyond <br />than the pe--mlt <br />for the billing <br />cumber ! &33 7 <br />TE:H 23-0038 1 6f- ' 0 L V <br />C V 12 -/I y 3 <br />