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Applications WIII B.Preened When Submitted Properly Completed.Be Sure To 'A <br /> i \I <br /> FOR OFFICE USE: �1 APPLICATION ( 11. . ,I 1 <br /> w _ (For Non•TrannferebM,Rovocam,Suependable `� 111 1 <br /> — ENVIRONMENTAL HEALTH PERMIT 2`g 16 WEu <br /> C3MKM IN ATE) WATM"Au" MAY 1 AL <br /> Application is hereby made to the SanJoaquin Local Health District fora permit to construct and/or Install IV" Opp <br /> Exact <br /> made In compliance with Sen J <br /> P oaculn County Ordinance No. 1862 and the •isles end regulations of Me SO �rOoee a District <br /> Enact Site address 1-7--ZY/--p/�% TA'C-r�1C yVi)y Jj'.al_.__.____ CnyfTown Z'neli' <br /> OwneiaNeme �Cl��j_C/F' c+_�iY�Y� —_ Phone,361-&47-7 <br /> Address�1 �.-Gy.TTr3eleM��n`C' Cly ��+e// <br /> Contractors Name _W&caI.f._-.titk'��-.D.Wlt Licenseez�j.6_ Businsee Phoria <br /> Contractors Address -&?Y'3imffJr'r4mv-A (Cd// Emerpeney Peons <br /> Is Certificate Of Workman's Compensation Iyneunnce on File With SJLHOT Yes <br /> TYPE OF WORK(CHOEEPEN O RECONDITION CI DESTRUCTI0 O <br /> WELL CHLORINATION 0 WELL ABANDONMENT O OTHER O PUMP INSTALLATION D ' PUMP REPAIR 13 <br /> REPLACEMENT O <br /> 1 <br /> DISTANCE TO NEAREST: Septic Tank -/,'*- _, _ Sewer Lines 10° pit Privy LU <br /> Sewage Disposal Field--J_._. Cesspool/Seepage Pit /f0 ' ONW w <br /> Properly Line Y&*_Private Domestic WNI-fC)Q Public Domestic Well <br /> INTENDED USE ../ TYPE OF WILL <br /> 0 INDUSTRIAL XCABLE TOOL Ds.of Well Excaelbn �~ a \ <br /> i�DOMESTIC/PRIVATE O DRILLED Ola.of Well Cuing ._ 3 V; <br /> 13 DOMESTIC/PUBLIC O DRIVEN Gauge of Casing )1. nA <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal, 3w y _ <br /> CATHODIC PROv ZCTION O NOTARY Type of Grout�I,YJ><14 e <br /> ❑ DISPOSAL O OTHER _ Other Information <br /> ❑ GEOPHYSICAL _ Sun aline led By , <br /> PUMP INSTALLATION: Contractor IVAO46p <br /> Type of Pull .P• <br /> PUMP REPLACEMENT: O Slate Work Donal <br /> PUMP REPAIR: O State Work DOM— --- <br /> DESTRUCTION OF WEU: Well Olarm1w - Approalm le Depth <br /> Describe Materlt' •nd Procedure <br /> rertlty that 1 have prepared this application and that thework wifi be dam M @CCOMAno*Whh Efn Joa01An Co0%0* <br /> ,late laws,and ruin and regulations of the San Joaouln LOCO Health DIStnCt. <br /> _e,mr or licensed ageM'n signature certifies The following:"I eeniy that In the performance Of MNwork for which MM pemMt <br /> is Swed. I shall not employ any person In such manner as to become subject to wor%"n'S CompenNlbn laws Of California" •� r'1, <br /> Contraeloes hiring or sub-conlracil"signature certifies IM following:"I ceniy that In the performance of the work for 140 thin 10 "a' <br /> pormit n issued, i shall employ person subject to workman's Compensation laws of Callfornia" <br /> I w�al7oatl for t Grout Inspection Prier to grouting and a finalInnpeellon. <br /> Cne <br /> S1d X _. .!/L._�GGx!-.tet _. Titer: OMAN <br /> (Drew Plot Plan on Reverse SIM) <br /> FOR DIPARTMINT UN ONLY <br /> Application <br /> ,�1ny,(y�IS,� <br /> Appllcsilon Accepted By �� �`^�_ ^ "�--`=- •� -.i <br /> Additional Comments'. ` —•-_-- <br /> Il Oreul InspectionInspection By-. Date =' Inspection BY <br /> Fee H Due:O ANNUALLY O Pati L"y O PEA SIn O[Asn O 1 a Asasi+sa By J.w_w 3r O.kat r a R.e._.w p Jor It <br /> aAw EXPLANATION BILLING ANAMAhCa t AMOUNT p� CHOCK= <br /> DATA oAn Apally[O -- - —AMOtM._._. t <br /> �m 00 <br /> MIb1UT1011 '. e.Y. <br /> OTAN <br /> rp• Ssntpe OF :O b A.wat No. t'rnMt Neawww o. <br /> �s��rpa�r-AnM1w Au 6eRn to wvwwaotTA�rMAt.*R PeAra*nsawus mleTOA A <br /> wlmva.,we.All <br /> faw maa»r aae�n <br />