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<br /> Applications Win Be Processed When Submlti W Property Coral" .Be Sum 7o f3i4rrThe Appilf:NIM1.
<br /> rs:ctr l�s>� APPLICATIOF
<br /> a s
<br /> --- IForNarTrsnthreble+,l� ,��.��•,,, �._��pUMPArVlfl:ll �-���� �
<br /> ENVIRON
<br /> I�PERM
<br /> _ ......
<br /> •- � P� r• � p,.�T �F r + _ iE �� Yom'' �}9
<br /> (COMPLETE IN TRIP:ICATE) QUALITY ,y �q�o ' i' ►
<br /> Ar,plicatlonIsherebx!nadetothe San Joaquin Local Health District Rrn Ar�tfuctand/or,in olltheworkhoWrld4iWWbadtThb.tyfptloaslod�
<br /> made in compliance v•ith San Joaquin County.Ordinance No.1 and the rules and 1lWd
<br /> San'46squln L.oeil tieaflh DistrleL� ,''} :�
<br /> Exact Site Address j MLEl�
<br /> � P_R �H' ♦ ° r ; + x; r"''
<br /> a SA L 1H phone 4i �.�
<br /> Owner's Nanta A. 1I_-Address `s�Q► _
<br /> COntractoYs Name rti0�'�[I;IN �._License 0 5�CRWL_Business Phone r
<br /> Contrsctors Addresa �i Eme•gency Phone
<br /> Is Certificate of Workman's Compensation Insurance On Flfe WLHD? Yea s
<br /> No s u 1
<br /> TYPti Ols`IIfORK(CHUCK): NEW WEkk
<br /> © 'DEEPEN :+ RECON01TION O DESTRUCTION©y'"+ �P'=f`; � "'`'A; � �. � ,•
<br /> WELL`CHLORINATICN D WELL ABANDONMENT 0 ~OTHER 0 PUMP INSTALLATION D Pi1MP REPAIp�;
<br /> REPLACEMENT OA
<br /> OI$TANATO NEAREST: Septic Tank. Sewer trines__ — Pit PAY, -.—�-- --= t' ,' t
<br /> ,.. . Sewage Disposal Field__Cesspool/Seepage Pit Other,
<br /> Property Line__Private Domestic Well — Publ'C Domestic well., V
<br /> Ye riff F ffED
<br /> USEW rtm OF VMLL l e
<br /> _ ^ :1INpt)$tftlAl' .0 CABLE TOOL Dia.of Weil Excavation
<br /> n�llS`TICJPRIVAI F C3 DRILLED Dfa.of Well Casing
<br /> 0 DRIVEN Gauge of Casing
<br /> s t .
<br /> "A RRItTt�nt AGRI�� 0 GRAVEL PACK t Depth of Grout Seal �.
<br /> T of Grout_ ,
<br /> ' = THODIC piiOTEC.:TION ❑'ROTARY i Type --
<br /> © OTHER Surface
<br /> Information
<br /> 0 DfPOSAI -
<br /> ��,.,0 QEOPFIY91CA4 Surface Seal Installed
<br /> 1%i110y 1lLLATt0N: Contractor i 1
<br /> 4 Fresy�.€ry- , 7 Of Pump
<br /> PW itEPLNCi6MENT: State Work Done (a i+
<br /> Pl
<br /> i11�A1/i» 0 State Work Dore
<br /> �'=Approximite Depth� - - -
<br /> 06AU&M OF WELL: well Diameter.— x r+
<br /> Describe Material and Procedure r 4
<br /> ' t hereby certify that t have preptamd this application and that the work will be done in eCoordancri with San Joaquin County, +
<br /> „Ordiftences,state laws.and ruin and regulations o1 the San Joaquin Local Health District ,. y q F 5
<br /> y R boron dw#W or licensed agrnps eiq WW"osrlllles t11e W wM4:"I certify that in thaperforrrlance of 1he Work forwhlch this permlt - •
<br /> }fiFftf '" t iii Isa wd,I shall not emaluy any person M such manner aa:to biome subJett to workman's compensation laws of Califon+la
<br /> ,.r /hnEortli6-QohtefCllrige[gnalvr/emek!!aHalfotbwi "1 Certify that inllioperformance OfltNMrOrkforvrftiChthi/ # f s
<br /> + ',j 'parittit:le
<br /> all employ per/ons sub}act to wotkmair'e compensarion Paws of Calltornla. '} � } }F t'
<br /> ' d.
<br /> t to gra and a IInI Impaetton.
<br /> ri S c♦ y. fit.+_ A� rW rr� ,i,ltle:. ", a Dour. r j y
<br /> (Draw Plat Plan on Re 81") •s R y,
<br /> 7PAR ENT USE ony
<br /> N- ted �= Da
<br /> #, Apii
<br /> pilcatlon AcCep � .
<br /> 'Addhional Comments-
<br /> + � Ph ll rWA Inspection til Ief n
<br /> y ir►specllon By Data — inspection dy'0*01 Date
<br /> -? 4''•t.+ i R IT Q"PER SITE (�EACH Ja 1 a n.enrlld aY.J&Oso $1.,:-.. 1 A Reownd h juv it 6 7
<br /> Foe M t?wt I] ANHu Lr ©. --- q
<br /> BILLING REWTTANCa ! -;A'.'AMOUNT&A C1 VCXCD `
<br /> Eu►SF r = 7tTfQ19 GATE
<br /> EDATE p/M1TTF,D _ AIMOUN
<br /> Lrao tinoN
<br /> PENALTY r.....^—...r.. 'b._
<br /> OTHER
<br /> OTHER
<br /> y yfi •i.
<br /> + / bete _ -9 baasyt �� at Ivo NMe�oA Mood
<br /> A/rLICMT—M MAN ALL COMta TC: WW"" HII"TAL Mtn'V"aaaTlrl t"fticts "M E.N11fLTOM1 AYE.P&Me 00 $7000M RA 068M
<br /> -� � ''�-°.;.;' � - _ .tee' .. rRti:-...:t�o"K%r�,dFi, i :�X• f - _� �� �,
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