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<br /> APP�.IC
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<br /> I . (FO Non-TrnlatenbM,R �I Q 4 PLfMP&WELL
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<br /> EWVIRONMENTAC HEAL EFipIT' r`
<br /> ? a 1NTRtP1.It;.ATE� ''rte tutl M<IT .`h^�1' ��� 1C��R r
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<br /> i►ppligtonisherehymedototheSsnJoaquinLocalHealthOist9"'"rorapermiitoconatructae freta(11�le�ork:herefndescribed I..,. plEcat}onfs _ 1
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<br /> made tn'eompAaince with Saz�Jsaqum County.0 i ca No nd he.' as and regulati the San ui oce.Health District
<br /> u v n 7% ' I Clty/Tawn e
<br /> E]IaCt$Ib Abd / y. 'ET
<br /> -41 , i? �&,h%' ,eg.. F kid-� `, -�0 4 - ). Iia Q(l .= `'��.id �g ..r s, s
<br /> r,�'OwrwrY Name
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<br /> A� pnh/ne
<br /> x� ��� a4' :, v,> i> pl�� 13uslness Phone` r `
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<br /> Co ntraotdt"s,Name r License "'
<br /> r �"F'InISY"s"fY r -�• s - �• - r � oc 3' � 3 n+i
<br /> oCorltraCto�a Address Emergency Phone d Y; J
<br /> f+� vra s! f� - rr --- - `
<br /> fiIs Cerllficate o!Workman s Compena$tlon Inali nca on File With SJLHD7z Yes.: No 1 r , �, sir ��,
<br /> " 'TYPE;OF 11Y041K.(CHECK) NENf WELI.❑ :,DEEPEN❑ RECONDITION�7 " DESTRUCTION O
<br /> 1 WELL'¢FILORINATlON fl WELL ABANQONMENT© OT ER PUMP INSTALLATION❑ PUMP REPAIR❑ h
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<br /> REPT CEMEhET �1` a b ,i o f T t ,-
<br /> ,�- ...fL x , , k a.:+ y, tn� 1 -, F i '^"'� .k^- - .it
<br /> c I"-,--DISTANCE TO NEAREST Septic Tanlc Sewer L1nes: Plt Pnvy
<br /> '+ ;�xr?rh , Sewage Disposal Field Cesspool/Seepage Pit Other ' r
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<br /> . 57; ?p �''` :r f " , ` ProperSy Llne Private Domestic Well ` w!j tet¢ r
<br /> Public Domestic Well a n
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<br /> �3.' �'" �NTEMdED IJSE TYPE t}F tMELL a
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<br /> 13siNOUSTRIAIL. © CA9LE"TObI Ola.of Well i xcavation , s
<br /> , DOMFSTIC?PRIVAT£ n.Z° ti- 0,DRILLEDI. 'Dia.of.well Casing , }
<br /> ©�DpME.,"T1ClPUBLIC QRIVEN:;f, Gangs Of Casing ;
<br /> i.•— 3OJIRRIl3A710N f, :.r n GRAVEL PACK Depth e}"Grout Seei3"
<br /> 1L7'CATIlOOIC PROT>CTION L1 ROTARY Type of Grant_
<br /> t3`Q�SPOSALj'r� ;r ❑ OTHER Qther Information ,•"
<br /> � 'n,GEOPHYSICAL n = urface Seai Installed By. yam"
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<br /> L;` Pl1tIAP INSTAI.LA1'ION Contractor ,
<br /> r : TYPe"of Pump "
<br /> PtlMP REPLACENEN7 [6�'Ftate work Done
<br /> 9 �a,✓
<br /> i ,Pt1MP REPAIR. y ❑ ork Done'.
<br /> 1 State w
<br /> WVOE8TRiJeCTION OF 1MELL. Well Qiameier Approximate Depth774�. ,
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<br /> .�a�,R� f ; _- �, �,`. r Describe Material and Procedure '
<br /> T,�;ei �Gy ACs }F Y - '.+- k^ :fit }
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<br /> ` C@ftl that I have prepared this'a licati" and that"the work will be done in accordance with San Joaquin County �`1r �
<br /> ;'k +c y y +r Y r I)`crab}. y PP
<br /> . ,„� prdmanees stale taws arsd rules and regulations of the Sart Joaquin Local Health District. r F y
<br /> ;" K i NorlaownerorlieensedagentaaignawrecertHieaTthefoilowirtg:"l certify that inti+eperformanceafihervorkforwhichthispermit , 1
<br /> #, F -fir,< Issued 1 shall net employ any person,n such manner as to become subject.to workman's compensation laws of California a
<br /> i� ... . .. -.:. -
<br /> i>e ; {Conlrastor'a hfriny or swb-Contracttng slQnaturo certifies the following:"i certify that in the performance of the work forwhich this ,
<br /> , i y`lam rpermlt 15 Issued t shall employ persons subject to workman's compensation lawc of California - ,a �,� j
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<br /> xI.. �� 1 11 t r#Gr«+t 1 pection prior t routing and a final I " ion ' _; ¢ `'' �j` �j't � ' I
<br /> i` g� 1 Ix Title: _ Date f� `�`6 ! ! '
<br /> til ,; Y h �s . raw Plot Plan on Rev a Side). ° j
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<br /> " FtIR DEPAflTMEN7 U5E ONLY " iyI
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<br /> V °�1°4,pplrcation Accepted By Date�2�
<br /> 7 ; Additional Comments:
<br /> r Plisse 11 Gross!Inspectlon h Ili Fieai lnspectlor}, I T 'f r-}
<br /> laspecuon By Date Inspection By Date `'1
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<br /> t•`!e 6,64;u ❑ ANNLtALLY 1©'PER UNIT'' PER SITE ❑ EACH ❑ January 1&Received tar January 31_ 0 dal}1 b Receivetl eVJuh 31
<br /> _ REMIT.„ 4 e
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<br /> /1MOUNT OUE CHECKED'. �
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<br /> -x�`� z d �` ;9ASE f%PLANA7 ON" :1. .DATE f!. DATE REMITTED _-. -'AMOUNT '� �.
<br /> i a.F'o > t FEE^
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<br /> 5 .`Raclired ay !,l• Oats _Recaps NO" .. ", Peima Np.. - !ssua�ste Data Made0 Delirerad. >-..
<br /> �' y`'- AppUCjiW_4tm01 ALL COP=TO: -ENVIRONMENTAL HFALTH PERMITtSFRVICES. ._ . 1601 F.HAZELTON AVE-P.O.eoa IOW�..STOCKTON.CA Y, .. . -
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