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> APDhcanons Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> I'FOR OOFICE USE:� I APPLICATION <br /> 1 (For Non-Transferable,Revocable,Suspendable) FLIMP&WELL <br /> ENVIPONMENTAL HEALTH PERMIT <br /> �—'—'--� <br /> (COMPLETE IN TRIPLICATE) WATER QCALITI <br /> A ppl Icaf on es hereby made 10 the San Joaquin Local Health Clslrict for a permit to construct and or install the work herein described.This application is <br /> m i 1 in compliance with;an Joaquin County Ordina ee No. 1862 and the ni!es and regulations of the San Joagldn Local Health District <br /> Evact S,te Address / 7.Z Cel` �16, ir .1 A•p sT�t>—: I 8— City/Town �eZ <br /> Cwrer's Name M az(r I � R .q,.5 I\ `-` Phone - <br /> AdrlresA g "I— - . . city A & <br /> & <br /> r^^m•a<;w's Name 0 l-ir. C�I, r. 4 Sef.N'> Lic,wise aIX,}� (e••3 Business Phone 7.y�'!. 3 V 7 <br /> C:,•i:•actor s ACdreES�rQ',i'� 5 Tetrt([ F Cr�. t5lid ��a er Emergency Phone `• M t . . - <br /> 1>C•Ttdicate of Workman s Compensation insurance on File With SJLHDI Yes -- No <br /> TYPE OF WORK,(;HECK;. NEW WELLA` DEEPEN E7 RECO -)ITIONO DESTRUCTION❑ <br /> 'TELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER EJ PUMP INSTALLATION E}-' PUMP REPAIR❑ O. <br /> RE?LACEMENi(3 <br /> DISTANCE TO NEAREST Septic Tank ��X'�. Sewer Lines Pit Privy � <br /> Sewage Disposal Field - _.. -.. Cesspool/Seepage Pit _._ Other <br /> Property Line7a__ Private Domestic Well Public Domestic Well _ \ <br /> INTENDED USE TYPE OF WELL <br /> 11 IN OUSTRIAL GI-CABLE TOOL Dia.of Well Excavation <br /> ❑ aEC:IC'PRIVATE 11 DRILLED Ora,of Well Casing <br /> DMESTIC.PJBLIC ❑ DRIVEN Gauge of CasingIL - <br /> 1n'<RIGATlf)N 17 GRAVEL PACK Depth of Grout Seal <br /> ❑ CAT.IOVIC 'ROTEC:ION E3 ROTARY Type of Grout <br /> :J DISPOSAL 13 OTHER Other Information <br /> 13 GEOPH'/SICAL Surface Seal Installed By. <br /> PUMP INSTALLATION: Contracror sa/r"N." FJJ <br /> Type of Pump 7'.:, e b iw HP J3 G: 1 <br /> PUMP REPLACEMENT: ❑ State Work Done Q <br /> PUMP REPAIR: El Stale Work Done <br /> DESTRUCTION OF WELL: Well Diameter Apprnxlmate Depth F� <br /> 1 Describe Material and Procedure y <br /> I hereby certify rtiat I have prepared this apphcahon and that the work will be done In accordance with San Joaquin Co•.rnly <br /> ordm MN:os.'tate laws.a•i•J rule,,aM regulations of the San Joaquin Local Health District <br /> Hems Owner or licensed agent's signature nn Jelnaloilowing: lcertify that Pas inn performance of the work for which tris pmmd <br /> ry ssuM. 1 shat:hot employ any person in such mariner as t0 hi`come Cllblerl to workman's compensation I.Iwit Of California <br /> Contractor's hiring orsubdomrecting slgnshareir .i1j"ten following: I .ertity Chit in Ill.perlorman.w Of the work for which this <br /> permit is msueri. I snaa errp:oy persons subject to Workman s compensarinn laws of Cahfofma <br /> I will <br /> call for a Grout Inspection prior to grcutlnt and a 1"Inspection. <br /> signed% �+ �.1 L 6�—,tai Tlee: I':.i <br /> �y C <br /> (Draw Plot Plan•n Rrve^.,> r ria <br /> FOR/pF.PARTMFjIT USF ONLY 1 •r <br /> PHASE I ) / / 1 1 G. �/ZQI <br /> Application Accrnd By i?1/� �. Lt+.�/�N^�""/� � .1 1' Data <br /> A(:o.rnnaal CipmmPht$ / -t L"{ <br /> Phase II Oroul Inspection Phaw 11/,teal ins bas �/� J�F: <br /> inspection By Oate / // Inlnrcbor.fly -try ��/ i c <br /> FN is Dia:❑ 44cLLL• ❑ rEN UN'T rn .if ❑LA(H 0 Jas •a N--."P. lllnuaq tl ❑ .viy I r fri rr.10,Ju•y P <br /> nEMit <br /> PLLUNO nFMiirWrl I <br /> nasi [rvlANn rli>N DATF. DAIF -ty."M AMOUNT DUE CHECKED <br /> AMt)OU-j <br /> • / �/{ {/�G U'IT <br /> F'•'. <br /> iiu "All'•4 <br /> I f <br /> of seal' <br /> O:uEP <br /> n MFw <br /> Dx» iii Il•,.v..n <br /> Aeries ANI-q ruaN All copies To fNValoNMrNtal HralrN eraM.f staviers iy' [ HAVELTON A".PC NNO 1, KV ieN CA 15]01 _ <br />