Laserfiche WebLink
CBltfttrs 1N I Bgopl <br /> 1! <br /> -OFFICE USE v A ' � N �. <br /> tF ff*Te�a#3te; errarMe,Suspendable) <br /> g PUMP&WELL <br /> ' s <br /> 4EALTH PERAIT <br /> - _ <br /> _*Ain <br /> ere�ryt to Joag r t't# tht�istrfct16ra: r' !t to constructardorinstalltheworkherein described.This application,is <br /> t p6t�Cnee d Min a No. 1W2 and the. rules and regulations of the Son M t„ocaf'He th District <br /> Etat Situ Adm$ / Cityti own <br /> _ <br /> AV <br /> �tcfdres <br /> s. <br /> �cr sh1n ticseBuairsess Phone <br /> Contractor's Address Emergency Pham <br /> is�i to of NorkmaWs Compensation insu with SJLFItr yes-1. No � <br /> ECK): NEW WELL13 7 RECONDITION Q DESTRUCTION Q - <br /> I ATfOf+i 0 WELD ABANbON1 fUT-0 OTHER:DPUMP- REPAfR❑TR <br /> l _ • <br /> NCE 7 NEARERT Septic Tank Sewer Lines Pit f>riy <br /> x _ <br /> K Sewagex014posal`Field Cesspooltseepaas Pit Other <br /> _ ?4r 4ty,Line i rivate F)arc lestic Vtleli Public Domestic Well <br /> f f DED USE <br /> TO OF <br /> Q INDUSTRf. CABLE TOOT Dia.of Well Ex c ation <br /> fl <br /> DOW� iY/�1'E Q DRl1tE0 Dia.of Well sing <br /> M 11 Q DRIVEN Gauge of C` ing <br /> 77 <br /> x .Q GRAVEL PACK Depth of drout Seal - <br /> Ar0 � ROTARY TYPe of Grt�ut <br /> Q ISPOSAL Q OTHER. _ r��ortr ti ri <br /> ' a, - :• Surtarcp til Installed By. t' <br /> v - - <br /> tif��f: Cf�+raetor ' � x <br /> # p <br /> a State Work Done <br /> - State Work Done <br /> flltiif+f Weil DiameterApproximate Depth <br /> DescribdV rial arid- re <br /> r <br /> l heray tflr lttat 1'have prepared tats _ and that the work will be done in accordaticewith San Joaquin County' ' <br /> ordiliane j e laws,and rules and re sof the San Joaquin Local Health District. <br /> Hon*e ti �agent's�l a flea tho fotloatIng "I certify that in thepert*rmbpCeofthe work for which this permit <br /> i fl�eptpbyy:ptrso ir>such manner as to became sem'_,. w8rkman's compensation laws of California." <br /> o+'s fi rilr�aaili0 CSi sf ettire Certlges the f "1'bertify th8 an the.performance of the work for which this <br /> per = issued, Vs' ertipt y sans bl tcr•workman's Winpens ion laws of California." <br /> 1 f aff fora r t fAspe r . ng a fiAal lnspe - <br /> X <br /> F. <br /> fDriw'Fiot Plan on <br /> �- neve <br /> Ft3fAAf�TMEf�FT:.USE t)NLY <br /> AppNCati try'' - Date _ <br /> Crr�trterlts: <br /> PTPfeSe fl txTiirtt fii F tff`F#naf <br /> Ins A <br /> ctron . Date trtpection By /A <br /> Vater <br /> i' f1E ) 11R1NUALLY .UNIT Q-PER:StTE C}.EACkt.` ``"' JBHu�"rY l$.igo++E .. Jarsuary 31 �] July t 3 R9�t fay July 31 <br /> � NG f�EtuiITTANCl •_= REMIT: <br /> " A AMOUNT'DUE CHECkED <br /> � <br /> DATE - DATf F JItTTED <br /> AMOUNT_ <br /> r" - <br /> Ptwn"110141 _ <br /> 0 <br /> h <br /> Vk <br /> tilE .t4LL - 7711 FiSktfiFl pEt R lit E.HAZ kt tt�" k0 c $T -To-K <br /> —� <br />