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� S <br /> VOW <br /> ApphcPflons Will Be Prpoessed When SubmllSun To Property CoCerapleled.BeSe SuTo Sfyn Tho Application. 1 <br /> :OR OFFICE USE_ APPLICATION <br /> (For Non-Translenble,Rseocable,Suspeneable) FUMP&WELL <br /> ENVIPONMENTAL HEALTH PERMIT <br /> LI <br /> (COMPLETE IN TRIPLICATE) WATER QCALITT <br /> Applicacon is hereby madE to the San Joaquin Local Health District lora permit toconstruct and•or install the wok herein described.This application is <br /> m,on in cpmpha••Ce won',an Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin LOCaI Health District <br /> E*act Sue Address / .2 d(bc. �? I^ �,' 1`c_J Cily?own <br /> Cwner's Name A"k �,r T -ta_- H Phone <br /> -� <br /> AdCresc Ay1 <br /> Sa - _ - - cur fl-Can.•.��-- -- - - --'-- <br /> Cen:•aelorsName >[TLCorA511-Spitb__ . Liconsex/X3_;, re Business Phone_ Yu--( 3_Y�7 <br /> Con;-actors ACd•/si��', QSTpC(,Jp•ti_.CjiW_<Sa er Emergency Phone <br /> I>Certificate of Workman i Compensation Insurance on File With SJLHD'r Yes No <br /> TYPE OF WORK IGHECK:. NEW WELL • — DEEPEN❑ RECO '31TIONI7 DESTRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER CJ PUMP INSTALLATIONS-' PUMP REPAIR O <br /> RE?LACEMENT❑ k <br /> DISTANCE TO NEAREST: Septic Tank + Sewer Lines,/dG =+ Pit Privy <br /> Sewage Disposal Field. CesspoollSeeepage Pit _ _ =Other_- <br /> Property Line7'a_Private Domestic Well . Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> C1 INDUSTRIAL GF-CA—BLE TOOL Dia.of Well Excavation <br /> I]��yIEJTICIPRiVATE 17 DRILLED Die.D!Well Casing <br /> OMESTICiPUBLIC ❑ DRIVEN Gauge of Casing <br /> Z- AIGATION - ❑ GRAVEL PACK Depth of Grout Seal <br /> CAT:+ODIC PROTEC7fON ❑ ROTARY Type of Grout <br /> 13 DISPOSAL O OTHER _ Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ Sd�.� _ - _ _ _ .._ - -_-._ . .._ ... .._. _ <br /> Type of Pump -_T4.n b /W -.. _ .__. H.P.�G__ <br /> PUMP REPLACEMENT: ❑ State Work Done_ ._._ ._. <br /> PUMP REPAIR: ❑ State Work Dome _ <br /> DESTRUCTION OF WELL: Well Diameter _ -_ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby eerhty -fiat I haw prepared this application and that the work will be done in accorCdnce with San Joaquin County �! <br /> ordrnmices.state laws, aril NIP.full requlations Of IhP San Joaquin Local Health District <br /> Home Ownerorlieensedagant'saignbluneen nlnslotiowing:`I certify,that in theperformance of the work for which bins permit <br /> r%issued. I shall not employ any person in such manner as to become%object to workman a compensation laves of California- <br /> Contraetorahiringorsub-contracting signature c :Nin the following: r_ertity mit In I.h-performgn�e of lne work for which thio <br /> permit is Issued.I stall eerplov persons subject to workman%eompensahon laws of California <br /> 1 will call for a Grout Inspection prior to groutint;and a final Inspection. <br /> r <br /> Skned% � • L TIM: r�- 1��.�.vw, Date:j'j.r•..y `I i d�G. <br /> $Draw PIOI Plan _A.1 1 .J <br /> FOR DEPARTMENT USE ONLY(• <br /> PHASEI / '1•' <br /> Application Accented BY �21.✓ rTR^✓.'N^e'"-;�Gf .( t• 1 Date a- ,1'rd . <br /> Aco-conal Comments .1 lrj <br /> Phase 11 Grout Inspection N- / 1 ` Phar 111/,.�Inal Insp relon i <br /> inspection By - Da!e ,4111)1J in%pertlon Fl, "�.-V! =!' 7<Ua1e �� �`� '`.�• <br /> �. <br /> Fee Is Dw:O N•+n.a. ❑rER pyiT [ ion i"T O L.C.. ❑ ,a a.­..,l n, 4­04'.11O _vii I r P.<w n,r,.:n <br /> nrklir <br /> P.cC E%nLANn•KTV PLL UNG nFM•^.•Pi S wMpVNr DUE CNCC.[ED <br /> DwTF. p.•r nF Vie r[p AMVU'rt <br /> tree <br /> Nu nA,.'•N <br /> I•nle .. ( 1 � I 1 <br /> OrrEP <br /> ".f. <br /> /8O 3y3 z m ,s��; <br /> In G 5 n,.ra-t.D•1• <br /> xWtlCwaT-erlUx%ALL COMaYO t Nw\ONYENTAL MraIT."-V-1 SrMYrCfS 110 t MAj[LTMA".ep Ge's"" 1. ) ,Ic. C.'s'.1 <br />