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AppNQa tan l YM Be Prucessed When Submitted Prepetty CongNbd.N Sura To Skit T11e AWICaMOw.7r <br /> i f `CE USE APPLICATION 0/111 1.v"l <br /> (for Non•Tt tnNasbN,Rsvocabls,SusPendable) PUMP&1NE11 <br /> r -� ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUAD" <br /> Application is hereby made to the San Joaquin Local Health District for r permit 10 construct"/Or install IM work hsloon dpwribed Thismomma <br /> r. <br /> made in compliance with San Joaquin County Ordinance No 18621tn(i the rtdes and regulations of the San JOM Mn LOOM HBG Mt Otelnet <br /> Exact Site Addresss.•244-PU- CityRawn (5cT' <br /> Ph0 ._.- <br /> Owners Name -.�SIr_r/4 r-_ _T�— mom-ay -;L -- <br /> Ar!dress _-Is' City <br /> Contractors Name =Lktertae Bu+ir`a+s Pt+one <br /> Contractors Address _ atrQx-f_ __. Emergency Phone 7 � <br /> ' Is Certificate of Wo►Itmsn's Compensation Insurance at File With SJLMW Yes <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN RECONOITION d DESTRUCT"O <br /> WELL CHLORINATION❑ WELL ABANDONMENT O OTHER ❑ PUMP INSTALLATION 13 PUMP WAIN 13 <br /> REPLACEMENT O : <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _._01-100 P"Po" <br /> Sewage Disposal Field_.. ^- - _ Gsepoov-sem ge Pit _..ice—cow. ---..� <br /> ' Property Line[ Private o nWic Well-,f_ Pubbc DCm1eMk Wv4-fflM--"'- <br /> !H INTENDED USE TYPE OP WELL <br /> ❑ INDUSTRIAL OL CABLE TOOL Dia. of Well Excav~- <br /> r <br /> ❑ DOMESTICMAIVATE Q DRILLED Dia.of Well Caminp <br /> ❑ DOMESTIC/PUBOC ❑ DRIVEN gauge of Casing e - <br /> IN IRRIGATION ❑ GRAVEL PACK 0"ith of Gout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of tarout <br /> 13 DISPOSAL O OTHER otherInlonniitlon — <br /> ,t ❑ GEOPHYSICAL $urlaoe Seal Installed BIr <br /> ' PUMP INSTALLAT10ff: Contractor <br /> Type of Pump-- __ M.P. <br /> PUMP REVLACtMENT`. ❑ State Work Done <br /> `r PUMP REPAtR: ❑ State Wont Done. <br /> `^ DESTRUCTION OF WELL: Weil D14msMr ApproxWm%DePfh-- <br /> Deacrlte Mate"and Procedure <br /> 1 hereby cenily that I neve prepared this application and that the work will be done In accordance hath San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> Home owner er IlOerlaed aseaft eWAlum prtlMes Mts IoNew1 8 -1 certify"in the peAOrmanco Of the wont forwhich this permit <br /> "s is iasueu. 1 sha'i not employ any parson in such manner as to became subject to workman's compensation laws Of CadfOrnla.' <br /> Com«sclera hirMg or wb4mwdroc*q*iWo two oerllMea hate ll- alrt@:'1 Certify that M Me Pufto mlance Of the wont fo.which Mb <br /> permit is issued.1*half employ persons subject to workman's compensation Was of CeliforrNa." <br /> 1 sunt oail tor� YHp or rond to yutMig aa tkw bv+e/C�tleR <br /> X �h <br /> (Drrw Plot Plan on Reverse Side) <br /> D uf>tE ONLY <br /> PHASE I 2zj O <br /> Application Accepted 9y aha <br /> If I <br /> Adaltional Commentrt T— <br /> liltw 11 Ore1r1 NlePeolkim �/ L c l�.tJ y t A.r� L �� <br /> Inspection By Day �• Inspection By <br /> Fee k our.0 ANW AUV O PER vaT_ O Pita w-E O Eaar O jWWwV I a m.ceftod by J«%rn 31 .wit r a meseft" <br /> Or Mir 31 <br /> " F eiLLlrrD �EMmANCE--T t - AMOUNT OUE CHOCI ED <br /> '• — SASE Ex►UWATION DATE OATS I IIEMMTTEO A'"— <br /> --I}-- <br /> n <br /> LESS <br /> T5!!` TION = <br /> / r <br /> PLUS <br /> OTNEA �+ <br /> s <br /> OTHER _ _ I <br />