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+rrN a. <br /> � rs <br /> 1 dt� <br /> "Ijff The ApplIu110E� Jd ;A � <br /> AppllcatlOns Will Be Processed When Submlttsd Properly ComP1e�d. r�L�J L + <br /> APPLICATION 1119T9 .D 'r'y<., <br /> FFICE USE: 11ll <br /> (For Non-Translsrable,Revocable,Su*Pen vC PU P V✓ELL <br /> ENVIRONMENTAL HEALTH PERMIT SAr1 ,OtQtJ({� t.CT� r �• <br /> 1 <br /> WATER QUALITY u- IIA DIS <br /> :TE IN TRIPLICATE) {� y/ <br /> in is hereby made to the San Joaquin Local Health Distrct fora permit to construct <br /> and/or mstall�bivork harem described.This appllcatlon Is <br /> ompliance with San Joa uin County r ante No. 1862 and lh�j ru es and regulations of the San Joa ui Local health District <br /> pq /�yc�,n �Cr - 7�aeA-)G.*t 1 yn I <br /> _� D �E_�%'/l City/Town <br /> e Address Ar/pp t�( <br /> St <br /> - -3----�-----"3- <br /> Phone /s- <br /> 460 <br /> ' <br /> `1'2SZ <br /> Name - <br /> city- AfAtf <br /> 7—! Business Phone .9!7 <br /> or's License s <br /> or's Address � EmargencyPhone <br /> , t <br /> nate of viorkman's Compensation Insurance on File With SJLHD? Yea No <br /> X _ <br /> F WORK(CHECK): NEW WELL.Q DEEPEN❑ RECONDITION C] DESTRUCTION❑ ^ <br /> ❑ PUM:-1 INSTALLATION PUMP REPAIR❑ yi <br /> ;HLORINATION C3 WELL ABANDONMENT❑ OTHER 1 <br /> :EMENT❑ ` y <br /> ICE TO NEAFIEST: Septic Tank _ Z.-'-- . Sewer Lines ------ �. _ Pit Privy I f <br /> Sewage Disposal Fie <br /> Cesspool/SeePage Pit _ Other. -- _----- - <br /> Property Line_�,�__-Private Domestic Well Public Domestic Well - <br /> rENDED USE TYPF OF WELL • <br /> USTRIAL <br /> E3CABLE TOOL Dia.of Well Excavation. <br /> �.DRILLED Dia.of Well Casing --.----G----- r j <br /> MESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> EST13 ---� --- --- <br /> IC/PUBLIC <br /> MEST1GATC/ GRAVEL PACK Depth of Grout Seal_— - -Q----�- - - " <br /> .r <br /> THODIC PROTECT ION JR ROTARY <br /> Type of Grout <br /> ❑ OTHER Other hInformation <br /> - <br /> OPHYSICAL urface Seal Installeu By: <br /> Contractor_INSTALLATION: /4p <br /> _- - --- -H—.P.---- <br /> ---. - <br /> Type of PumpgI!! <br /> REPLACEMENT: ❑ State Work Done_ <br /> REPAIR: - _ __- -- ------ --- -- <br /> - - -— -- <br /> ❑ State Work Done - ----- ------- ---- <br /> Approximate Depth <br /> _ ----- -- ----- <br /> Well Diameter _ - <br /> RUCTION OF WELL: -- --- ---- <br /> Describe Material and Procedure <br /> I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin County s� <br /> ordinances.state laws.and rules and regulations of the San Joaquin Local Health Dis' ,ct. , r <br /> Home owner 0r licensed agent's signature certifies the follOwing:'l certlty that in the performance of the Fork for which th-purmlt <br /> Is Issued. 1 shall rot employ any person in such manner as to become subject to workman's compensallon laws of California" <br /> Contractor's hiring or sub-contrac+Ing signature cert;;iea to-iwing:"I certlty that in the perlorrndncrr Of the work for which rills <br /> permit Is Issued. I shall employ pt rscins subject to workm,in s compensation laws of California" <br /> Iwill c r a Grpt Ina on prior`grouting and a final Inspe lo r 't <br /> Date: <br /> �r � Tillo' 9•e <br /> Ted X W <br /> (Draw Plot Plan or •�^" :'e -) '•%�� <br /> OR EPMRTME T tJSE ONLY <br /> �- -� /6////7? <br /> PHASE IDate ,y <br /> Application Accepted By <br /> Additional Comments Pha�►wl J Final Inspection ft= <br /> Phase u CDate <br /> Date aroul Inspection / J! } / + ry <br /> 1 1/ InspecuCn By <br /> Inspection By L• .� <br /> Fee Is Due:❑ ANN'JA•LV <br /> l ❑PERiJNiT ❑ PER'ATE C1 EACH <br /> ❑ ROtbi-ed ay Janus. <br /> January 1 6 . REMIT <br /> bII UNG REMirT ANCE $ ALrOUNT D'-IE CHECKED <br /> TECI <br /> BREMIT Ah10UNT <br /> o <br /> ASE EXPLANATInN DATE DATE y / <br /> FEE � 170�� ✓ ,', <br /> LESS 1 .Q <br /> PRORATION 1 r„ <br /> PLUS 0 _ ✓�ll;..- v y "l v <br /> PENALT, 0 (� <br /> �S <br /> OTHER q <br /> OTHEH <br /> Det.. ,.,; <br /> 1601 F NAZELTON AVC P O tlu.'t!i4V 70OCKTON CA 9120 <br /> .e.t Al Il1MN ALL COPttS TO tNVIRONMENTAI HF AI I PFRMIT FE RVICES <br />