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r Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. APPLICATION FOR OFFICE USE: pUMp&W[LL J (For Non-Transferable,Revocable,Suspendable) (.c:rFZr I1 ENVIRONMENTAL HEALTH PERMIT WATER QUALITY application is L( OMPLETE IN TR PLICATE) per orinslalIthe w0rk herein described.This Avphcat.On is ht (,,:ymade to theSAnJORO d�LocaUiealthDistrictlornp in Local Health U.ct made in cempl ante with San Joaquin C<�unty Ordinance No. 1862 to a r�les and requlatrons of the San J�II�+ L- .� .L•�flJ .CJ .S./- City low, -J/'�/!�/t Exact Sate Address 7 • Phono Owner's Name _._-. -- r' r-L---- Address - -- -- ,Gy__ d 3--3 %J-_ Business Phone cS.,�L,/l�,'" __- _ Licensee If:!, 7 _ Contractor's Name _-- -- _ :Arsl __&J or Emergency Phone --_-_--__ Contractors Address . .;20.N v '�` )c No r n is Certificate o1 Workman's CompensAt,Dn Insurance on File With HDA JDITIO IO ❑VuMINSTALLATION V ` TYPE OF WORK (CHECK; NEW WELL DEEPEN❑ , RECO" P INo R ALLATIION❑ PUMP REPAIR J WELL CHLORINAArION 13WALL ABANDONMENT ❑ OTHER ❑ REPLACEMENTf1 Sewer Lines _- Pit Privy v DISTANCC. TO NEAREST �epPc Tank Other.____ - Cessp001.SPepngg Pit)ewage D,sposal field Fuhl c Domestic Well _— -- - i PrOP"r•v Line Private D"eShr,Wgll .e INTENDED USE TYPE Of WELL i D ❑ CABLE TOOL ia r•i We"Excavation ❑ INDUSTRIAL- DIR of Well Casing DOMESTIC'PRIVATE ❑ DRILLED ❑ DRIVEN Gauge of Casing ❑ D _------ y DOMESTIC PUBLIC ❑ GRAVEL PACK Depthpth of Grout Seal ❑ IRRIGATION ❑ ROTARY Type of Grout _- ---- ❑ CATHODIC PROTECTION D OTHER _ Other Irinrmation CI DISPOSAL Surface SealInstalled By _--- -- - -- ❑ GEOPHYSICAL �__s�/ --� PUMP INSTALLATION: Contractor __- Type ofPuinp —Se.06�1►f S 6ld HP -- -- — ----- - —Ol1 PUMP REPLACEMENT: ❑ State Work DOrtelr -- -- D Sinto Work Done,- - ----- -----._.-- PUMP REPAIR: Approximate Depth --- Well Dlnmeter —- --- t DESTRUCTION OF WELL: — ;inscribe Miller al All, Procedure - - , 1 1 I hereby certify flint 1 have prepared this AP and that the work will be done in accordance with So n JO4quin County I JoegWn LOCAI HnAlth ntstnct oidin3mces.state Inws And ru1M and rpgt1i tions Or the San permit Home owner or licensed egenl's signature cerlBies the following:"I certrly that in the prrkmel ante of the work for which this ,L H issued. I thrill ce ed age Any PnrAOn in sUth m?^ner as to become subject 10 WO rkrr'rn iiuri`nAnCe01 thepensation fwork for wh Ch this �. 9• Controctor's hiring or sub•cont•scling signature hed toNwo tithe 10 coring''"'certify Awsthatof California."in the permit is issued 1 rhAl1 LTi'i`v t� I 1 w I e 11 for a Grout Insp.•rion / ipr to grow Ag and a final Inspection. �.l Dale: _ uu rr .-- • t TINe: Signed 7�r �� `�r 44 �r11/►'nrA (Draw 1 PIAn on Revere Side) - -_- - - -- µ✓- -_AOR DEPARTMENT SE ONLY PHASE �+ !� / ,,� ..- n� Date O niod Applicillitic Additions crit% Photo 111 final Inspection L— Pha.if grout Inspection Impechon By �f�Uid'— Date .v Ira _ Inspection By r)Ale L.J v 1 6 nwr�•vM BY lw^icer 7� Q ),cry i S tT'rprvM ar JuN 31 O Arvog IAL 1.V U r•1.A'1N.. �M'n it ❑ !�G' _ - REMIT .- tree 11�W: f A MrUNT DUE CHECKED - i-- 4t1.Liltf:', L._^t•r...a.rt i ..f.. bM9LLy�