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+PY,•J`•is ` ,e.. x..n, ..r •"-x:'uc.-'4EJ.?�':�t.�t*tt�r. r.',. l � •1..:'ac$�l.�nY��+Cl�'�'.e"iP'�'�- Y;
<br /> Applications Will Be Processed When Submitted Properly Comp ailm To l3ign The Applkilton._ ,,1"t
<br /> z FOR`OFFiCE USE APPLtCATIrJN
<br /> �� N
<br /> - For Non-Tneisfirabie,Revocable,SuspendabN)
<br /> _. � ._ .. ..
<br /> ENVIRONMENTAL HEALTHPER N �0P,.Q
<br /> W-ATEII QUALM.:
<br /> (COMPLETE IN.TRiPLICATE)
<br /> h nJoa uinLocalHealthDistrictfornpermittoconstruetand/orinstelltheworkherelndescribed:Thiaapplieatloris?�r�
<br /> �.Application is hereby mad@tat a 58 q n r
<br /> r:•<
<br /> inade in correpliande with San Joaquin Coun Orli a e No.1842 and the rules and regulations of the Sen'Jcaquln Local Health'[istrict
<br /> t Exact Site Address _1 I
<br /> CitylTownf;`♦ �` a
<br /> i4ddresa W^ _SQA Clty
<br /> '-Contractors Name .d Llcense a 979 /a_ Business Phone' ; `
<br /> w "3 rrJt1h�-+TA"5 b
<br /> Emergency Phone'.
<br /> ,�- 'rs�Addr'ess• �+1•
<br /> .Contracto .
<br /> x +Is:Certifit ate of Workman's Compensation lnsuranee on File With SJLHD3. Yes NO"''`" I; { ``•• ' ?�
<br /> TYPE OF WORK{CHECK) NEWWELL '_. DEEPEN❑ RECONDITION❑,: DESTRUCTION❑::. xf -: ,; ^M V'
<br /> I .,NrELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER-13i PUMP INSTALLATION❑ PUMP REPAIRS , w,
<br /> ��REPLACEMENT❑� ' �
<br /> I� ' .DISTANCE TO NEAREST" Septic,Tank Sewer Lines Pit Privy , �r
<br /> r. 5 Sewage Disposal Field Cesspool/Seepage Pit Other
<br /> v,. ..-.
<br /> Property.Line -' m
<br /> Private Doestle Well Public Domestic Well ya ~
<br /> 3' n a;, �.1'•
<br /> 17 ,RiTENDEA l!$E ? TYPE OF WELL { r•t �j ti 3 �i '�, i.
<br /> '� ❑ INDUSTRIAL s { ❑_CABLE TOOL Dla of Well Excavation M
<br /> © DOMESTIC/PRIVATE O DRILLED Die.of Well Casing
<br /> DOMESTIC�IPUBLIC- ❑ DREVEN 1 Gauge of Ceaing �r �iJ ;
<br /> ,C3 }_RRIC3ATiON ' ❑ GRAVEL PACK Depth of Grout Seal ' " $Ah
<br /> nQ ❑ ROTARY: Type of Grout,
<br /> ,CATHODIC PROTECTION
<br /> ❑ OTHER - Other Informatlan ,
<br /> 94-,❑'DISPOSAL f
<br /> rz0 GEOPHYSICALr Surfaoe Sea!Installed By
<br /> -PUMP INSTALLATION., Contractor
<br /> -
<br /> ley; 'ri �3< g State Work Done _ H.P
<br /> ._PUMP REPLACEt11ElIT -71
<br /> PUMP REPAIR. State Work Done I
<br /> DEA roximate De th
<br /> 'E!
<br /> �� STRUV'TION OF WELL. s Well"Diameter pp p
<br /> Describe Material and Procedure
<br /> y7H A�l t � - �
<br /> ji
<br /> }
<br /> f: � JtF�{'y wl hereby certlfy'that I have prepared this application and that the work will be'done in accordance with Sen Joaquin County r�v"
<br /> a ordinanc@s state taws and rules andregutatlons of the San Joaquin Local Health DistrlcL
<br /> x �, ' litomeowna'rarllcensedapeni'asigrraturoeertii+esthefollowinq: 'EaertltythatinthepertormanCeofth@workforwhlchthispeRnit� '
<br /> is issued I shall',not employ any person in such manner as to become subject to workman s compensation lawn of Cagforrrfa s •_
<br /> 3
<br /> Yrtf ` Contractors hiring ur sub<pntracting signature certifies the following:"l certtiy that in the perfarmence of the worts forwhlGh
<br /> t, permit is issued,i shall employ persons subject to workman's compensation laws of California
<br /> two „i y: ti T�
<br /> ST ; I will eatlior's Grout In r to grouting and a Ilnal inapeol .....
<br /> n ,, ;
<br /> Tine o
<br /> (Draw Plot Pian on Reverse
<br /> s
<br /> ARTl1AENT. $E
<br /> x,Appllcatlon Accepted By Date .
<br /> ,`Additforial Comments �• 1
<br /> >I Y Phan 11 Grout Irupectlon �i
<br /> 11 Final
<br /> ate len '
<br /> rs w <InspacMion By" ., D ' �`' inspection B Data a
<br /> ANNUAt.Lr r ❑ R UNIT ❑ PER titTE'°- 0 EACH ❑ January F•6 RxeWaO BY Jaawry�t - O JuW�ld Me�ivW BV July 0/'' F.
<br /> c a4�r a y?: ls c REMITSr
<br /> C•* _FY ` iM t_r, ''` - 61LLINfl REMITTANCE AMOUNT DUE -.t CHECII[D�}- '
<br /> eASE EXPLANATFON l -.DATE DATE REMn TER -{ AIJOLtMTi7,. „
<br /> s:
<br /> _ yr crLESS- k? r
<br /> PRORATION
<br /> "C r y Y f*r
<br /> PENALTY
<br /> $if•3 rhe b OTHER �,r". I , _ , `t" y `f+f'• ' A,.-,' � :
<br /> 3 r l �b dyko
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<br /> 1q.L - Ipuane�.00% MAI
<br /> ppCMd bys pNmNNp
<br /> CWO�pTO: tM+ OMM!RAL 1LALTN 101 L HAtaLTON ALFA.ear a,0�
<br /> APPLIOMR—a/TNM . Drllirarad •:.;:.,. ,
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<br /> eTOdtTOM,CA
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<br /> � ��SYr• '��' S_�.�. :R. "� ,.r�' ,C,+ .;ate., �,� � .rr�' -'re...3.� ;
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