|
APplic3tions Wltl Or' F�� P g,sed When Submitted ProperlyCom Completed Be Sure To Si n T► A
<br /> FOR OFFICE USE: i f Application.
<br /> APPLICATION
<br /> 1 t 1 (For Non-Transferable. Revocable,Sus
<br /> pendable)
<br /> ENVIRONMENTAL HEALTH PEWIT rump:V11tL
<br /> (COMPLETE IN TRIPLICATE) WATER QUALITY
<br /> ApDlrcabon,s t erebY made to the S9n,!.qq,�,,,��).al Health District 10+a pg►mrt A f',O Y
<br /> made m compliance with San Joa u.^ r,,. , ,r m%tall the'.vork herein descrlben Th.s aCpl,cat-on,s
<br /> 77- ./- Y "1'^anr�NU 1862 and the riles ons of the San Joaquin Local Health District
<br /> Exact Site 4ddressL= •wFL T- .� p
<br /> t
<br /> Owners Name u,+�L '�,� 'Z -�vT/�r�`
<br /> Aduress , / r � ' Phone ,3 ��er y ?LOWJF
<br /> Conrrartor 1 / 7 V
<br /> s Name City `//�...C'.�•�wc�/ /
<br /> Contractors Addresq� /pnroone- y W
<br /> IS r;r-r�!rCate t 40�mergency Phone 3 Gi / 7
<br /> Of Workman s Co-r-nsat,ryn 1'. tnr.e on Fdo With S LHD� Vas L�
<br /> TYPE OF WORK (GIECK) NEYJY/El.l n On
<br /> ❑ RECONDITION C3 DESTRUCT ON❑
<br /> WELL CHLORINATION U WELL AHANr0NMEh ❑ OTHER ❑
<br /> REPLACEMENT 13 PUh1P INSTALLATION[3 PUMP REPAIR C3
<br /> DISTANCE TO NEAREST Septic Tank � �'�f c /
<br /> .,ewer lines /,3 C pit Nr,yY
<br /> Sewago O,r:;.rr;,• I r,ih Ces•po011Seepage Vit
<br /> Prpparf�LPOther
<br /> ,n,• Private Domestic Well PtrbI1C Domestic wellINTENDED USE TYPE OF WELL
<br /> ❑ INDUSTRIAL ❑ rnHLE TOOL // v
<br /> 13 DOMESTIC PRDia.of Wen Excavation
<br /> IVATE ❑
<br /> ,WILED Dia Of Well Casinj ' V
<br /> ❑ DOMESTIC/PUBLIC ❑ 1)"IVEN ...
<br /> Oaupe Of Casing
<br /> L7 IRRIGATION
<br /> ❑ ',rIAVEI. PACK _.-•.-........ . ..K, ..�»,r...�
<br /> ❑ CATHODIC PROTECTION g�-•T;',TAI,, �Dlh of afoul 5►al s'f� f
<br /> ❑ DISPOSALType of Groat
<br /> ❑ ��Tlp r
<br /> Other Infomallon
<br /> ❑ GEOPHYSICAL `' _` 1
<br /> PUMP INSTALLATION: �, , , Surface!'reallneraned Hy fr�5.+�/�
<br /> ,' rnr.fur
<br /> T n.,. f NUn•�
<br /> PUMP REPLACEMENT ❑ ,,.• A'-Irk Done H P
<br /> PUMP REPAIR: ❑ ' •,. ..Work Done
<br /> STRUCTION OF WELL ameter
<br /> ApprU�lrrlttle Depth
<br /> " ••''r•Malr•I,al and Procedure
<br /> I nanny CerbfY r 'q► 1 parr- ; •' , , 7 oil , :UplicaPon and that the wore wai tw done In atCCMancie wllh!Can Juaquln CtNlhtV
<br /> ordinances %tato taw% a,•.,.. ,...1 r,,,l,,lahunt of Me San '
<br /> ..t>aiyuln local►Irallh QlalrlEl
<br /> None owner Or Iken"d agent•argnalun drhltee LIN�y�,�� 1 l rrUl That In the
<br /> r!'%SU" 1 shall nc,t rr., „ ibMOMlMIg, Y petfU,nWnCeolthOYrWrlorwhr(lhth•spMM,t
<br /> p 11 n• 1"" S,Ch manner as to become fubiecr to YroMn*n a co/N(Nntiatwln taYls of C4hh»414
<br /> COnlroctCes hiring ur sub-contracting signature cerl flef the IONOwing 'l re►N►y fhalin the / '
<br /> Wrr•''1 rr. �%r,r•U I .'r/rl,.r. PwUIm.nctlbllhwMtNskMrM,ChMIs
<br /> l �„hlecl to wr>r�msns enmirenr►ation 1•ws OI Caltlf`fhla
<br /> 1 Wil cal,�&OLul Inspection prior 1vgroulln%andaflnsfMNOeeUOw,
<br /> Signoo X ��. <�ve6� Title. &*"L41_A"►0t.'9V0'— Dole,
<br /> Draw Plnf Plan on Reve/M Smtel
<br /> PHASE 1
<br /> FOR IIIPARTIN?UN ONLY
<br /> Application Accented fly +..... J�J IMto
<br /> AAd.tinnal COmmont% • y - 4
<br /> PhstxIi drout inept-coton / l 11 IInM IMMeNen
<br /> in 'c tion low / r";,
<br /> v V .r ;�`�• .,• . p
<br /> !� / Insprcf,nn By �,i� I✓j� Dain (� /i1 (q�i
<br /> EN Is 011e: 0!•nl Q rrw•: '•avrr.«1 II/...�w.rr r 1• 0 P.r `•rbr..,—I
<br /> Ae
<br /> 1w. uly,.l4.Ks 1 MgMYy
<br /> CIArl 1-•r/ egyrrrgD aVrhh/Emig Caecato
<br /> / 440ou v/
<br /> 44 L.]�
<br /> ' M•. ,. ...••• . r 4.... . � 41•K t1i,M ry.,s,s I�ifr�I/M
<br /> t�� •M►K•N, al•l•wN•l.Cn�rl%rU Iti. � •VVI NI• Nr aLtM araWt
<br /> � aetrrcgs /sol g wVeta+OM ave ea ar lllee •roearaw a run
<br />
|