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is.rih:,w-, t 1 J / �r,ry ..� .- VVVN.,.,� s r Appllcgllons Wlfl Be Processed When Submitted Properly Completed.lRfL�ur•To SIQn The Apptivatl APPLICATION S S � _��'r _ FOR OFFICE USE: ti-- (Far Non-Transferable,Resrocablo,Suspendable) �&WELL a I:NVIRONMENTAI.HEALTH PERMITSAt DIS --� WATER QUALITY N A ficatlonia"% f (COMPLETE IN TRIPLICATE) Ilcation is hereby made to the Sen foaquin Local Health District for a permit to construct and for Inslall the work herein described.This app oaquin Local made in compliance wit San Joa uin County Ordinance No.1862 and the rules and regulations Ru� n$ OCKtOI7 Ffeatlh Distrlet f� X00 :. Marsposa Rd. Y Exact Site Address ----- --— `! Eugenia Murchison Ls Phone �y w<' Owners Name _ 5t6r t«' '�� • 1.1 • City- rs.v :.Address - etc S Oe ri�'. Lieansep3770 11b -x9002 �. S s., C1ontractor's Name r 2t) ;Ji C C one d• EmRrge,cy Phona r:g goniractorsAddrest� :. i as Com ensalion Insurance on File With SJLHL`7 Yes X No '•. t Yf 1 JA ,,t.y is Certificate of Workn7 TYPE OF WORK(CHECK); NEW WELL❑ DEEPEN❑ RECONDITION❑ DESTRUCTION❑ ? ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ ' i WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER a REPLACEMENT f Lines s Pit Privy DISTANCE TO NEAREST: Septic Tank _- �— Other f 1 I! Selvage Disposal Field— Cesspool/Seepage Pit — ^o Property LinePrivate Domestic Well Public Domestic Well A TYPE OF WELL INTENDED USE Dia.of We Excavation ❑ INDUSTRIAL ❑ CABLE TOOL r't '�•; Dia.of Well Casing , TE ❑ DRILLED ❑ ESTIC/PR V DUfi� Gauge of Casing + ❑ OOMESTIC/PUSLIC ❑ DRIVEN Depth of Grout Saal ° $' " [3 IRRIGATION ❑ GRAVEL PACK ��• 4 F .,�.. _.: �a`�•�,.. ❑ ROTARY TYPE of Grout J [I CATHODIC PROTECTION Other information ` Fa DISPOSAL ❑ OTHER ' .' ' Surface Seal Installed BY: ❑ GEOPHYSICAL {' •` PUMP INSTALLATION: Contractor i H.P.P Type of Pump -HP—Sub-to r ACEMENT: ❑ State Work Done�I1S_ PUMP REPL r I ' .= ❑ State Work Done ; r rf�h' PUMP REPAIR: Approximate Depth`• `'. Well D.ameler i,�'•,.f'. DESTRUCTION OF WELL: w..z'• Describe Material and Procedure t hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r '! ordinances,state laws,and rules and regulations Of the San Joaquin Local Health District. l .. Home owner or licensed a9ent•s slgnallife certifies the following:"1 ometsub'act to woy that In the e kmangs compensation nceOf MillworktQaws of Calilorwhich this Permit nle S J Q N :s issued,i shall not employ any person In such manner as to bac ! ! Q g Y Gonlratlors hiring or sub-contractln signature certifies the following: t cerci[ that In the performance of the work for which this . k permit is issued.I shall employ persons subject to workman's compensation laws of California." ' R and a final Inspeclfvn. t wl e11 for a Grnu t tion prio to grouting-Sn Signed X — Qa2GGrl/ 50-0 4,7b_ Title: 0_vme — Dale' a (Draw Plot Plan on Reverse Side) "'. FOR DEPARTMENT USE ONLY w'•- ;�` PHASE I O� �� Date �� "•' -xy a'•` Application Accepted By — — —" Additional Comments:----- -- - Phase III Final Inspection " , `+•' Phase 11 Grout Inspection Date r Date —_ Inspection By _ - Inspection By 1 "r . _ _ _ _ __._ -. _ REMIT FEE F!e 11 Due:❑ ANNUALLY PER UNIT ❑ PEn SITE ❑E�•Cf r+ January 1 a Rec#. By January JI ❑July I&R•ee"'ed Py.1Y}Y31 j-- I - -_- - BILLING REMITTANCE - -_ AMOUNT DUE CHECKED EXPLANATION REM171ED A HT BASE DATE DATE �.+� L FAESS I ..� ORAMN—N I EI PLUS PENALTY OTHER ;t{ OTHER _ ._r�..rn-••r•�.y�.��Yli,•4wk.+ L V :� }.��. ..V..1 Pei T,1 No .....y..._,.. .:D• M.11•Q-'s,.•1.,�",`_Dtt • r � ,fir'• Date Rece-PI"a nec""d by APPLICANT—RE7VRN ALL COPIES TO: ENVIROrrYENTAL HEALTH PERYITlSERYICE4 1601 E.HA2[LTOK AYE»•.O.aw atet`� Me TOM�s;�sl ` a 4