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SM <br /> F02.:tiF1'lf:f� SFSL: I6o1 Z, .Liaseltou Ave., SCocktca. Calif. <br /> Telephone: (M) 455-6781 <br /> APPLlC11TIt7R POR fid d. SMI at MIP .PERS I Pernit No,. <br /> TILS 8ESi9iT EXPIRES l YEAR MM DATE 15$M hate Issued <br /> f J'7-q,q74E' ,� leee In Triplicate) "lar <br /> : 2tF -lt d wad <br /> Applicaeion is hereby s&xde to the .toeq*sia LOCa1 Bealth District for .a permit to coa4tract <br /> enddor irsstaf.l the work herein deaeribed... JbIS; app].SCatian is made fu Couplionce With Salt j&" <br /> City Ordinw= Ito.. IM MW the Rales and R*&vUtioas of tae San 44 a uiu Local Health D"IMUt. <br /> 303 ADDRE5S/LOCATION + CM= TRACT <br /> Xa <br /> OWMtto li=e ?hose <br /> 3ddresa a City <br /> TYes Of UM (Cheek)t MW WELL DEEM /� R ITION 1� mT==m <br /> • rte IXSTAi.LATIDSi L-7 nw REPAIR 1^7 PUMP PMACHMENr. / <br /> other d 7 <br /> DISTANCE TO NEAUM, SEnIC TANK SEWER LOBS PIT MIVY a <br /> $FHACB I1LSMAL Fx ET;SSMMUSEEPAM V T _ O <br /> INT IOi%p DIE TYPE or *RLL t Jt.TIt>li S PYCALZGNS f� <br /> Industrial Cable Tao1 Gia, of WOW Excavation 77— <br /> Dowstic/private _,��Drilled ilia. of well Casio$ <br /> eacie/pnbifc Hriv" "age of Casing <br /> IrTigatiaa Grad rack wth of (;v*Ut Seal , <br /> Other itatnYY + Type of Grant <br /> Orber <br /> -Other Ioformation <br /> S'iF:LF ISIS'MAATIoN; CantTartor <br /> Type of P-W .1?• � r <br /> Pt7!!P RRP1 At ': f7 State %Wrk <br /> M9 It AI,RState hark Done <br /> kh <br /> .9i.4 M=103 Of fiMZ . boll. DiaMtcr Approxinerw Depth <br /> Deseribe.Motetial aad Vrocednre <br /> L hcltcb9 agree to coa+piy with all Imm and ragulatioaQ of jhe Saw Joaquin S.arsl iiealt IIistrict <br /> i and th* Stere. of California pertaining to or r1 9viAtf," +Feil e6=trnstUM- 4iitkiri PiPlM DAYS <br /> after copletion of sy work on a new well. I Will Curaish tho joagnin Local Health District a <br /> HELL DR •LERS RSPORT of thb well and notify them before puttI08 the well in use. The ab.ove <br /> ? information is true to the best, of -ay knowledge and belief. <br /> # Sum TITLE <br /> MVAW vMT PLM w ww=311 SIDE <br /> R DEPARY2�1' 3J5F t1RLY <br /> s p4ASE I- <br /> APPLI ATIDN ACCEPiLD BY <br /> ' AWITIONAL CADS MMI <br /> P . iI MPECYZdbE PEiaaE III J1I. �It <br /> IffiSpECLfbR <br /> By .DATE k IRS wT EM 8Y ^ tiAU <br /> Q LL IOR A CMM WSPSGTi4t PRWA TO d33TI4FG.AND-FIM& ITh1$4iSC' 09. <br /> E H 242$ <br />