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p� <br /> i _L Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFF1c USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) / PUAIf•,. WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Dlsb:cl lore permit tocon,iru,t ant: Inflalithowork hereon described Thi,application do <br /> made in compliance with n Joaquin County Ordinance No. 1862 ande rules and cgpulatwns of the San Joaquin Local Health District <br /> Exact Site Address Cil k'A�'Frf�TE k: E �l" Sr+v.r/ J`T FtC..?/N/.� City/Town S�T•c R'7SN_ - _ -.__. <br /> Owner's NameiPhone - <br /> _��IAEG �/� 'a�/- <br /> Y a� — -. <br /> Address_S_y JZFGq>:y Ai -Aeref el✓j _�7pD city — — --� <br /> — -- — -- --- — <br /> Contractor's Name .(c�f./. �['-off-- --.- - - - Llden.e a?777FS Business Phone ?1C, <br /> Comractors Address of.?rOR,17Y f/.E\',G`��[•DGC__-- Emergency Pnone <br /> Is Certificate of Workman's Compensation maurence on File With SJLHDo yes No <br /> TYPE OF WORK(CHECK)'. NEW WEL69 DEEPEN❑ RECONDITION O DESTRUCTION C3 <br /> WELL CHLORINATION O WFLL ARANDONMENT ❑ OTHER O PUMP INSTALLATION PUMP REPAIRO <br /> REPLACEMENT O <br /> DISTANCE TO NEAREST Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit . .__. Other___.. <br /> Proper•.y Line Private Domestic Well__ Public DDmmic Wall <br /> INTENDED USE TYPE OF WELL <br /> U INDUSTRIAL O CABLE TOOL Dia,of'Nell Excavation <br /> DOMESTIC/PRIVATE O DRILLED Die.of Well Casing _6 <br /> DOMESTIC/PUBLIC ODRIVEN Gauge of Casing -10 _.____ <br /> O IRRIGATION J1p�GRAVEL PACK Depth of Grout Spill <br /> OCATHODIC PROTECTION 9 ROTARY Type of Grout -1.____ <br /> O DISPOSAL O (-711CR Other Information <br /> 0 GEOPHYSICAL __ ---_.- <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor,?&i 'JT - ___ <br /> Type of Pump_ -Ga ov __--_ H.P. <br /> PUMP REPLACEMENT: O State Work Done._____ <br /> PUMP REPAIR: O State Work Dons <br /> DESTRUCTION Of WELL: Well Diameter __ .. _ __- Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance wflh San Joaquin County <br /> ordlnaneee,state laws,and rules and regulations of the San Joaquin Local Health District <br /> Homeowneratle Road agent's lgnature eertlBee the foliowklg: L„rtlly that In the performance of the work Sof which this tvrmil QQQsss��� <br /> It Issued I shall not employ any person In such manner me to become subject to wo0man'S compensation laws of California" <br /> COnhaC10Y11 hlring a sale•contecting signature cortlKes the foaowing:"I certify that in the performance of the work for which thh <br /> permR is issued,I$hall employ persons subject to workman's compensation laws of California." <br /> 1wJillll call fa a Grout Inspection prior to grou8ng Sed a final inspection. <br /> SgnW `, <br /> X :•L -- - ----- - Tow.. r�ZyiK`i: D... S• ,rP-J`Z �z <br /> (Dew Plot Plan on Reverse Sae) �D <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Acceptel By-- -'--- r.,t.p.-4--------- ----- -- Dats-�J <br /> Additional Comments:....__.-._ _._--__-.__.—_-_-.. __ __— f <br /> If Greul)AapeNlerl Phase III FMN Ilwpealbn <br /> Inspection By -Of 1-7--m 4g bets J��'"PL _._ _ ._ Inepeenpn Ry Date . <br /> Fee IS Due!O ANNUALL V ❑ r•r n i,N.r O RR SITE O 111tH C Jeauwy I a IeNswse ey Jsewry]t ❑mW• s nece.ee ay J.Ir n <br /> EMIT <br /> Mar I•rr SNAndN aDATED <br /> 1 RfATa AMOUNT DIIa <.HlnaeD <br /> DATE <br /> DAT[ REMITTED <br /> r«.-.JJHT <br /> FEE <br /> LPNMIITIDN <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER 1 <br /> N M e NR lto IoSS 1.5s . <br /> w Nrwpr Nu IL,rrLreee MN _ —kMPM - pw•w•wn <br /> rIMLIC1wT—aRp11N ALL CONea TO [NVIRONA1ERTAL HEALTH M MTAe11v1C[$ IMI L HA[[LMN Aye.PA.M[ee 1TOcaTON.t;."., _ <br />