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<br /> F Appliontions Will Be Processed When Submitted Progeny Completed.B•Sun To Sign The AppllcatlolL;
<br /> FOR OFFICE USE. APPLICATION
<br /> ,. .
<br /> (For Nen•TransMrabk,Retiecable,SuspendabN) r
<br /> - PUMP&WELL v-
<br /> ENVIRONMENTAL HEALTH PERMIT J• 3 r "�
<br /> ' OMPLETE IN TRIPLICATE) WATER QUALITT
<br /> :Applicalion is herobymadeto IheSan Joaquin Local Health Distri
<br /> ctfora :,
<br /> rmi
<br /> 1� ttD CO. S}rOCf and/ r e "
<br /> o in.,tall h +�
<br /> t ework•herein
<br /> destrlbed.',Thia a iicatbn Is
<br /> 7c made In eomplianoe with Snn'Joaqu.n Couri Ord' ce No:t86 and the rules and.ragulations o}the San..)oagtiin peal Health DistriCL
<br /> E7�ect Sile Address`
<br /> t. City
<br /> /Town eaf t}'y
<br /> Owners Name c,G 3 LACYJ/.Wfpda,l7� Phone1j; {
<br /> r
<br /> y-Addreae Citti
<br /> z� rConfractors Name`; License N N Z Z Business"Phone Z• Z '� .
<br /> �s'Contractors Add "-'
<br /> ,�,....
<br /> reaa Emergency Phone
<br /> Is
<br /> Certifi
<br /> y<e• cate.of�Yorkman's Com n
<br /> - , . , pe aatlon •ns ranceon File Wi1h�SJLHb7 -Y
<br /> �, TYPE OF WORK;(CHECK) hEW WELL E - z
<br /> h L. DEEPEN❑" RECf�NDITION❑ DESTRUCTION
<br /> 'll�IWELL,CHLORINATION❑ WELL;ABANDONMENT❑ OTHER LLD -•PUMP INSTALLATION❑ PUMP REPAIR❑, 1 ' u '
<br /> -"REPLACEMENT C7 ,
<br /> -
<br /> �`M a]iSTANOE TO NEAREST S tic Tank
<br /> cv gPr. _ Sewer Lines _Q_a--- Pit Privy. "`
<br /> Se wage.Disposal Fiefd 0(J ,
<br /> �— Cesspool/ page Pit—�� r :Other
<br /> Property Line lQ Private Domestic Welt Publ:':�omestfc IArell
<br /> I INTENDED
<br /> USE ;TYPE OF.
<br /> k 0 WELL
<br /> INDUSTRIAL ❑ CABLETOOL ,.{ion. xa
<br /> S
<br /> DOMESTI
<br /> •�= C/PRIVATE
<br /> ❑ DRILLED »•tip =, r ,,
<br /> Dla,ot.welf Caairigst Fw
<br /> ❑DOMES' /PUBLIC - ❑
<br /> DRIVEN .` Gauge of Casing � ,
<br /> Kk❑
<br /> IRRIGATION „-GRAVEL PACK Depth of Grout Sesl
<br /> CATHODIGPROTECTION ROTARY `. . Type"of'arout
<br /> A Q�DfSPOSAt © OTHER": Otherinftirmetian;
<br /> •GEOPHYSICALSurface Seal Installed
<br /> �� PUMP INSTALLATION
<br /> �* Contractor
<br /> J _ Type Of Pump
<br /> rrt PUMP ME
<br /> REPLACENT
<br /> a On State Work Done � s� p�_•:'-��s'"+`/n?��; I;
<br /> }��PUMP 11 Oki
<br /> ' d-State Work Done
<br /> y3 DESTRUCTION OF WELI. ;' �•: '
<br /> Well Diameter Approxlmete Depth
<br /> DBaoflbe,lUtaterlal and Procedure. _-
<br /> F -
<br /> 3 .ti
<br /> hereby certify lhit`I have prepared this a lice}Ion and that the work will be done in accordance with San Joaqufn'Counh ;` I''
<br /> r PA
<br /> < r ordinances state laws and rules and regulations of the San Joaquin Local Heelth,DI I ICL
<br /> x y 'Horne owor l'cerised erlt•s sjpnature"certifiaithe follopriny:"I certify that in the perlorittance of thework forwAich thiapermit r.'��s;��
<br /> Is issued;#ehatl not em employ an
<br /> p Y y person In-such manner as to become subject to workman's Compensation laws of Califomie ,�
<br /> r ¢ f t:ontraotors hlrlrr¢or sub-cortlracpng itgnei%"eertilies the lollewing:1 certify that in the performance of the work forwhich this
<br /> rr: permit is iaaued I shat)employ persons Subject to workman's compensation laws of Califomia:
<br /> r�strk rl` •�`
<br /> on prior to grouting and a final Inspection
<br /> PkS yyf
<br /> hl f t- i
<br /> Signed)( F ' � ��Tide• : . .., 7' [ �,• .
<br /> � Date ��.#`• ;
<br /> (brew Piot plan on Reverse Side) t r _ ...
<br /> w
<br /> FOR PARTMEIT USE ONLY
<br /> :stiT�PMA8Erl
<br /> s�t Application Accepted By'j
<br /> �'���Addilfonal Comments- Date Orr
<br /> No In - E
<br /> a•T r epeCtl♦N1 Ptlsse l
<br /> III Finalnelw4lon 1 il ad
<br /> Ina tion
<br /> P� Date
<br /> ti3 rY Inspection BY Date
<br /> " p;410
<br /> Oct,
<br /> y t } FN Ie DIN'O ANNUALLY D PER UNIT PER SITE ❑EACH ❑ Jenu�ry a
<br /> 1 Race ved a Janva 31 ' a ^" � �+
<br /> h 8th r ^+•r _ s -. _ - _ Y N ``D July 1 d R�eNr�d�y JuM 31
<br /> id . SASE --'tcxPLANAT-ON 6:ILLIN6.-- .,REMITTANCE �. ",�.: '• - ,'REMIT=.F .
<br /> DATE
<br /> DATE AMOUNT OUE�. CNECKEp� gra
<br /> REMITTED
<br /> re FEE r- AMOUNT ':
<br /> fi r . LESS
<br /> - ,' i � PRORATION - f _ 't � .c•c F �J�,C�'F 1
<br /> �4 ..A.PLUS
<br /> PENALTY -5 -. - r ti r r.r3^�Y •
<br /> y
<br /> I• - R�plvWpbY .OilyI 77 7
<br /> Rios pi NO ,..,_;WIWd Di1lYerid-.
<br /> APPLICANT 11[TURM-ALL COPHe TO -'�MVMOM MINTAL kULTH KMIIT/eNIVIC6a ^'•.lea!L.IIAZELTON A `' ',_.•*"i ¢1-•fi.
<br /> - ` YE,1A ea sose eTocrMK CA�spel ;
<br /> r # ,_< , -,, .�.,,, +,.... 9 yr r }_ �, t,- •'-�� 3 �'�- , HB-3 , i
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