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<br /> Applicakons Wl:l Be Proctl.,csr.d.,'titin FWbmiNad Properly Completed.Be Sure To Sign The Application. _ l
<br /> +� P'3R OF :r: APPLICATION
<br /> (Fcr Noa•Tronxferrble,Revocable.Suspendable) ! .
<br /> 4 ---_-- -- PUMP&WELL
<br /> s" _- . ENVIR3 ,,MENTAL HEALTH PERMIT
<br /> __-�
<br /> i^ iCOMPEETE trs TAiPLICATE) IMUER 01JALITT W
<br /> t $• '4 i•
<br /> Apo!lez.tior)ishy
<br /> ereb mads;oche$nr„rcaquinLcxaEHesit11 ;ori;t;uinpermitteconsiructand/or in sial Ci
<br /> �
<br /> trctk, maria;ir.rcm'aliance wlth;nn JOrqui,l Cour ty Ordinance No. lb',P enef the ruins and regu..,tion,of the San Joqgyln focal Ilh GiSirlCt. T
<br /> Enact �Il.Address—G A-Vpe,T 11,, ._ c��s.£���_. r.7_ r.= __—�— Cit /Towr.
<br /> Owner's i r; '4R.d yeytr•_ `�. 1�' �� ��..-�Pho�ne—C74” tl
<br /> . a �. ddr eY'r Y
<br /> ! Cortreclor's Name ^ . _ _. , ..._ L!censo#7�47 3usiness Phone-4 •. i
<br /> Contractor's Address is x_ )?± � _�#I_r___ En;ergenry Phone N/
<br /> is Cer'tifica:e of Workman's Oomper.R;ion I,xrance J 1 3ri;;41'il;;SJLHD? Yes No
<br /> TYPE OF E'lr.iPK (CHECK); NEW V.1ELL 7E'CYr-N 1.:J gFC:ONOI T ION❑ DESTRUCTION(:)
<br /> ;y7 WELL CHL:JRINATION, ❑ WELL ABANDGNI+EENT CD C"7!-+t n ❑ PU,b1P iNSTALLATION❑ PUh4P REPAIR❑ �
<br /> ..
<br /> p l! RE:PLAC.riY9ENT01
<br /> /at, r
<br /> DISTANCE"'J NEAREST: Septic TasLir:
<br /> k ;it=r•e: es 10,00 Pit Privy ---.—
<br /> ^aewage Disposal Field {_�_� Cesspool/Sr-epage Pi;
<br /> _ Other
<br /> Pro erty Line�� Private Oonect'-Wnit" Public Domestic Well _
<br /> x
<br /> INTENDED USE TYPE OF WELL
<br /> r+ t
<br /> ' ❑ INDU
<br /> ;^S 57'RIF:L c CABLE TOOL Ola.of Wed Excavation---�
<br /> 7.
<br /> DCESTIC'1PRIVATE E7 DRILLED Dia.of Well Cosi
<br /> � Msng
<br /> ... t� COMESTIC/PIUVLIC Cj DRIVEN Gaup(,.of Casing��—� in;' f'.
<br /> p,!GAT'.ON C1 GRAVEL 11ACK Cepth of Grout Seal
<br /> �}
<br /> CATHODIC PROTECTION
<br /> 0 m .ROTARY Type'it�itout—_--__ ,_ -
<br /> r;• ❑ DISPOSAL OTHER — _ Othr-r information
<br /> Q Ge OP' Y fCA Surface Seal installed By:
<br /> irk
<br /> 3' PrATP iNI,''TALLATION: Conh'aclo.
<br /> Type n:Pump— ------ H.P. ---- — w
<br /> 4J PUMP REPLACEMENT: ❑ Sta.z
<br /> PUMP REPAIR:
<br /> {a State—1-fork Done w--_.-__-- ---._--------- __ u
<br /> DESTRUCTION OF WELL: Wc#I Dicrne$er—.._--___— -,,..•„--.—.—__. Approximate Depth
<br /> ” Descr:bv Material ar.d ProccJu,e
<br /> �;flat I have areparetl:his application and that'sile woe}.will be dOhE ir; accordance with San Joaquin Cnunly
<br /> ,Ncreby f;srt�
<br /> n ordinrnues,stn; laws.en n les:nd rr gulatlons of 1,ye San Joaquin Local Health District.
<br /> lfnrneowny orticnsed�>Egen'ssignstc:rer_ertifloothe:o$fowing;"Iceitif�+thntfntheoerh)rmrncc;aithewarkfor which this permit
<br /> is i69u3d.!nhull n t r pkr y'ny person in suClr manner as?o berorne:ubjacl to workman's cornpensation taws o!California." d`
<br /> Contrtgs/ni s tiirin arsWb c trcciis i1 ig;,aturm r,,•raWF-, Ihr fulfcwing:"I cer,ify that in,hr,,perfolmanco of the work for which this
<br /> pertni fi i�3;.catt,'l St; II F�,oy psrs.ns to v.orkman's compRnSatlCn IawS of California." _ � x•
<br /> I wltl 17 fora nut spa )ten Prlor iC outing and a ilnsl inspection.
<br /> ` Signed X -- -- —_—_ Tille: —y Dale: ? :
<br /> (--raw Plot Pipn on Reverse Side) a
<br /> �f. -- --- —FOR DCPART&f !NT USE ONLY
<br /> E.
<br /> PHASI
<br /> AppiiC:ntion Accepted ON---�? �7"^.^_ '
<br /> ' ice;�-� J�— -- ------- gate
<br /> Additional Comments:—._—..'�
<br /> Phase f: n3pec11on '} �--- — Phone` F3[taI irs3eCtlon 7'
<br /> tr: action By 4-.�+_ 7- al CL I { ��� 1
<br /> sp __ �-D .e _-- _ Inspec!lon 3v".[�,�A+ya-_ .jA-- Date_��-
<br /> Fee lb DUO:U ANNUALLY _M M.P.UNIT �PER SITE {�EACH L"] January s d Rrcr vetl By January 31 f i_•,:y l&Recarvi+d ey Jelly 7:
<br /> ''+S• I E)ILt.I`JC. .._REAlITTANC:E -1
<br /> • 111 BASE Ex?LAN.iT;ON — —�—.REMIT-
<br /> G1't'L I DATE i,Ttt' AMOIJNT OIJE CHECKED 4 ^# art
<br /> •!fA- '.ti —_�_ --_ —'-�-----' ------'�".. a'rA T AMOVYI•_—_
<br /> ;�•x � s FEE -- I__�1��---}- --- ---`-----�--- .� —.�7 [��" ?ti l;:'
<br /> Less
<br /> r PPOP ATIOV
<br /> }I - ,r d!A TY
<br /> si
<br /> 1'r1'� fleCO!•!Ctl t1Y Dnln Rxalp[Baa- Ppr:m1 Pin- _ IllNaliOe Dale Mailed n411vur^C �-
<br /> '}� APPLICANT--r:t.7L'KR1
<br /> AU COPIES TO: EPdW,1OkM�Y 1 AL PMA L FF1 PERM ITr$EAVICFS 101 F.HAZE',TUn AVX.,P.O.Bas?009 STUCK•:
<br /> y_✓;. 1j_��Y�.,,�.lJia'ii✓ P`n'��
<br /> S'"SEE'''.'^
<br /> 0:•3VX':."J(' ?!?,�ii7'T�RS7!d`."a'.1;Y^ 'RY�t'ig'�SR.YfiY.{T7[?ti�Pc'411�14t?�!FS3:1Ri's;r•
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