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Applications Will Be Processed When Suhm 11ad Prnperly Completed Ba Sure To Sign The Apel caT►Oq <br /> FOR OFFICE USE: I APPLICATION <br /> (For NOn•Transfe/able,Revocahle,Suspendabte) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATtR DUALITY <br /> Application -I hereby mAr7R10thwranJ- #giiin : 1 01naI!r,n,•,t., ++•,•nparrn.t!',r.nn�!r,IIt40rl ,,rrn%fAlln''O-A'*V-f'h*f Tl%.% Aran. s <br /> made In CDmQLAnfe with San JOAqu,n 1 our+ty��,rfrnancr•'y, ''-, 1^� ? rule%an-1 r.rqulAhons of this%an lopq�ln Lyca/►rranh A+etnct <br /> E_xAet Site Address .i '7,7 /�� �' h~� a �• 1701 Town �y f <br /> Owner,NAmn 467e <br /> Addrwss ISIS S C /1rr0�er L-A ►Mr City �p�' <br /> Contractors Name ^_A/rLP.1 license It B1r1•nnSs P%rtr.e t <br /> Contractor It Addrr.sA Emer,]erw y ^none sr7 <br /> 1%Cwrlificate of Workman!COmpensat,on Insurance on File With`SJLHD7 Y,-S NI) ..•� <br /> TYPE Of WORK r''HECKI VFW WELL❑ DEEPEN C1nECONDITION❑ DFKTRUCTION❑ 1 <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP tNSTALLATIONlK Pump RFPAtn❑ <br /> REPLACEMENT 13 <br /> nISTANCF. TO NFAnFST Septic Tank ,Q Sewer Lines '0�' Pit Privy <br /> ! Sewage Msposal Field Cesspool Seepayr Pit Orne. <br /> ? Property Line 1?e Private DomestlL Well /-St-0 Puhi,C Domestic We+I <br /> INTiNDED USE TYPE OF WFLL U <br /> M ❑ INDU-,TRiAL ❑ CABLE TOOL Dia of Well Fxcavabor �` { <br /> ❑ DOMFSTIC PR1VAIS ❑ DRILLED Dia of Well Casing <br /> ❑ DOMESTIC'PUBLIC ❑ DRIVEN Gau-e of Casing 1� } <br /> ❑ IRRIGATION l] GRAVEL PACK Depth o►Grc.ul Seal )I <br /> ❑ CATFIODIC PROTECTION ❑ ROTARY Type of Grout <br /> f ❑ DISPOSAL ❑ OTHER Other Information <br /> " ❑ GEOPHYSICAL Surface Seat Installers By <br /> d PUMP INSTALLATh' Contractor (7 L/11 ee — ry <br /> r4, ., � HP �d <br /> Type of hump <br /> PUMP REPLACEMENT: ❑ State Work Done --- <br /> 'UMP REPAIR: ❑ stale Work Done - <br /> A <br /> ..STRUCT `A' 'F WELL Well Diameter Approx.rnsfe Depth _ <br /> _ r <br /> Descrihe Mater,al and Proceiture <br /> i I nereLy „ertify that I have prwpired this aPOtrcafion and thrt the work w+ti he done In atcorOante se.th San Joaquin CounfY A <br /> orf 'lances.stale+awe, and rulers and rNulabafts Of the San Joaquin Local Hpalth Dlstr.ct . <br />>� Monte owner or IlCertsed agent's signaturecertifiesM IfollO.eNq I certify treat m the pwrrnrmante Or the work fpr whish MK pe+mit <br /> ISSUed 1 Shall nvt employ any Person in sUCh mar•ne•aS to bwcomw SUbfwCI►o workman f CO•^C'!^tal-011 law$Of CakifOrnla - r <br /> contractors hiring of sub-contract"signature CemfMs k»f-"*Wfn0 I erhfy treat in tnrt pw+fnrmancw or t'�r work rot wh.Cn rhrs <br /> w permit :s isitt led I shall rim.,k'y M"SOns subtect to workman s compenSADon Ilvars of Caftforrl-a . <br /> 3 <br /> I will call for a Grout 7I�nssppeection�w to grouting and a final Insroctior, <br />} . Signed X �`-" �/ Tittle: Dale. - - � <br /> (Draw Plot Plan en Reverse So") <br />' yT FOR DEPARIMENT USE ONLY <br /> n ' PHASE i <br /> Apnticabon Ac,epled By — <br /> Additional Comments -- ----- - ----- - - l /- -- - - --- - — --- I <br /> Phalli It Gro d InW.Iion ��// III Fin <br /> f ln%pection By ___ ___ - ____ Date _-- !---/_ InTf+ee!r1n By� Date <br /> Fee It DUI: ❑ ANNUALLV ❑Pfa UNIT p PFn aiTt ❑FACN ❑ Jaq,ary 1 A n..-e-d By Js.w,y Ti ❑ J.tv 1 a n.e -d of J.•v it <br /> . Rf 01 1 <br /> BAS£ FxPLAwA7iON BILLING REMiTTAvCE S AMOUNT DIJ[ CP*Cir£D <br /> DATE OATf RFMITTFD ,t,kp 7 <br /> FFE <br /> L'SS <br /> ' PRORATION <br /> PLUS <br /> PENALTY <br /> O7MER <br /> L.THfR <br /> � r <br /> Lie....rM,. Deli Rwcepi N., 'Mm.i NO IN.aaKe Dalw Ma•'M D��•re,M — <br /> AeeL1CA14T—Rr TURN ALL Cowles TO ROWN1ONW01TAL Nl ALT.e erRMR.411FI rICCa 1861 a M"RLTON AVK..PO.sax tae a70"ToN.cA 86170. — J <br /> r'[ <br />