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s ApplicationsWill Be Processed When Subri'itted Properly Completed. Be Sure To Sign The Application
<br /> F011 1IF 5E LSE: APPLICATION
<br /> Co f V ,(For Non-Transferable,"Rerocable,Suspendablh, : PUMP&WELL
<br /> ENVIRONMENTAL-HEALTH'PERMIT
<br /> (CO PLETE IN TRIPLICATE) WATER QUALITY
<br /> =7 rr`Ut"t"t .l - .t
<br /> Application is hereby made to the San Joaquin LocalHealthDistrict for a.permittoconstructand/or!stallthew K-Ih&eindescri �appiicatipnis
<br /> •s_.fiv..1L7 #+ldw rr• 'i.�G.i ,4rtf.1 ..r ; s'"'.•F.. ,- 'r,¢.• -
<br /> made in compliance,with.Sart,loaquin.4o ty Ord" a��Ce NQ.,1862.artd rules:ander,Freg Alatons,of_the�Sarl,Joaqu�n Local Healt District.
<br /> v1dF f, - ):.i:.i !- U.-G 1''+i i'il3l£,
<br /> Exact Site Address Citylrown
<br /> Ownei's�Nartie �bzv G�• �' ir% •-ti ,- � ` .- cn+�.. .s .:: = . --
<br /> Phone4f-5#flv.� "9+1vcyc '8! Crt 1- "=
<br /> Address
<br /> Contractors Name :1 afzi- T i - . ' ' l'o' �.
<br /> ce
<br /> rase# �B- isi1� " 1 �
<br /> us ness:i�hoile� 1 zi .,�
<br /> Contractors Address 4 YO'v:tEinertjency'Pi,oria°R no
<br /> Is Certificate of Workman's Compensation-Insurance On File ith SJLH_D? Yes K No
<br /> --
<br /> TYPE OF WORK (CFlECiCj�f+(E1111 1NELL��DEEPEN' - RECONDITION Cl-� DESTR[JCTIQ[�f
<br /> WELL-CHLORINA-TION,11-----WELL'ABANDONMENT ❑ OTHER-❑ --PUMP-.INSTALLATION'® .PUMP REPAIR❑
<br /> REPLACEMENT❑( # r 4
<br /> ,
<br /> DISTANCE TO NEAREST: Septic Tank y -- -- - -'
<br /> P Sewer Lines Plt Privy +� T Yt.
<br /> Sewage'DisposaEField.--:- _ ----t Cesspool/Seepage Pit------•---�-- Ather-
<br /> : Property_Line is
<br /> .Private Domestic:Well i Public Domestics Wei€
<br /> { INTENDED USE # ; TYPE OF WELL,, ' I z - #
<br /> ❑-I NDUSTR IAL-- -- - --❑-•CABLE TOOL- - - -.�- Diar of-Wel[-Excavation,
<br /> {� D_OM_E_STIG/PRIV_ATE f ❑ DRILLED { }Dia. of Well.Casing
<br /> DOMESTIC/PUBLIC:��_ ��.. -Q pgIVEN ? "•1 ` -, -
<br /> ,: t I Gauge of Casing
<br /> } -_._! __-13--GRAVEL-PACK -'(r 4--- i .Depth-of Grout-Seal
<br /> ❑ IRRIGA,TION-=- r ! r
<br /> ❑ CATHO_DIC PROTECTION- ]- 4 ❑,ROTAR.Y_ E TYPe of Grdutli
<br /> �DISPOSALT '-- - ^-Q OTHER {~� -� Outerlrifo on -
<br /> 0 GEOP14YSICALr l l 1 _ k Sulfate SeaLlnstalled By
<br /> PUMP INSTALLATION ; r # t i;5 • _{ {I
<br /> V�ntra �r 4 7 k'• i ! J 1�
<br /> :TYPe of Pump;
<br /> ra +'
<br /> PUMP'REPLACEMENT r c 3 �, µ
<br /> $tate�Worlr�Done w j f ( E
<br /> ' ; yh -til ! ��-�->• 1l`. � <'L 1. 1sL1 }
<br /> PUMP F!,.
<br /> r` l U�S1OCk Done -
<br /> DESTRUCTION'OF WEL
<br /> L z gg ¢ Well,`Diameter PRroximate Depth' -` r 1
<br /> -t .I+3
<br /> a ` .3 Ser c+w ,' 3'tws -$ h s y` •nr �•ti i
<br /> - 3 u 1795Cr1 a Materral'and Procedure a' -* i a
<br /> •.•y3 '='1 'il`'.' !r` 1 _-T,*_ _ -..,5 t. k -'! ?[..e +/Y. 'I. '�`Sw-i'IA'F-
<br /> I.I hereby. certify that I�preparedrthi a�pliCatton an that the wor�cuwill`be ci'orTe.in>accordance;wI Sart aquin County k r,
<br /> {_ -" -ardinancesystate11 and rules and'' ulations of`the Sar ,i{oa�quln'L`oca Health Distiict �?' a � ��'� �,.,y � '
<br /> 3 y i u ,M.,�r•''3jrr ,,,, •.�f'_+'�.>�'-'��T.t t� y-t s>r, y
<br /> Homeowneroriicenseilagents`signaturecertlfiesthefollowing- rtriy'#herrtheperformanceoftheworkforwhlchthispermlt� '
<br /> :,, ,.�..-.;-ter tr
<br /> x ; is issued i-st1`ali riot employ:any person it such�manne�as to become subleCtLto wol Icinan$compensationJaws-of Califoaii l" +�
<br /> } a.y S' r r!. a,-r t '.•.,i:...;,; • 3. _.. 3*. kt 6:,"� .5"`F 3'7 T f--.]lY;. 'Ywb�' ,µ
<br /> I Contraclors hiring or sub contracting,signature ceetifies thgfoElowln "I certify that in the performance of thawark#orwhich this
<br /> permit is issued 1 shall employ osteo s s t workman s.campensatien laws Of Callfornla ; Ef x . `
<br /> --� i i j '• ; P }sf,. p ' 1� :a1 it 3. hE3 { s _
<br /> V 11call fo o Grant InspectI N r° gro ; snit I-ins on t .M -} ti } ! tyiJ3
<br /> t' ` Yom.#"P -- .•Y, _ � '�'' ## •:9 1 1 i-_ .'..` °" ,;' A.'+; "� ;"£ '; ,
<br /> Signed- -
<br /> - ; Draw Plat,, On:Reverse Side)
<br /> ..l--__^.. L _ ,; sa t�rawr.. .'.a1,_.:ar.1�e.#_<.;- ' ...•++e..cr.' pL� ' _yam',i
<br /> FOR Dt'sPARTMENTUSE!
<br /> .._� ONLY
<br /> II PHASE
<br /> - -AppEicatjort Accepted By- i 2A 1 - FF
<br /> r i Additions!Comments: 1 �F r # I" s' (. ,' .t.�, .I h JI"tl-'• r a 'F4+r I r-
<br /> ! Phase 11 Grout Inspection- j - t_ Phase 111 Final p ttan �� }
<br /> 'inspection BY- - _ Da#e.--l- 1 _jam_ ' Inspection.BX
<br /> ii--fes s _ �.ty
<br /> 1'`x,... I —•_F-
<br /> -� FeeIsDU@:❑ AIVNUAL;LY s' ❑;PERUNI i ' •,r ._,i_,. �
<br /> PER'SITE "'� CEi�-- ❑-Janus V&ReceWd'al JaAtnary T[T- I'--T ReCeivBQBy�Lry_
<br /> � _ €- .CREMI'f.� � .-.
<br /> `IXPCJINA7[ON:-.— BILLING. '_.''.REMIT.TANCE= -5 --
<br /> E' ,AMOUNT DUE CHECKEp•-, -
<br /> F DATE, "' DATE;'
<br /> RFIVRITTED) AINOUNT l �'
<br /> FEE
<br /> I _.._ „
<br /> LESS- -—iJ c _.� - i- -r' - •Y'- L L- 1 _. - -�--
<br /> PRORATION j __, i. { i 1 1 i.
<br /> "PLUS—'
<br />• �1 PENALTY'OTHER
<br /> '+ -f- i F a• -3,. - ""," _-j - - "�--•
<br /> TT!
<br /> 7
<br /> 3 OTHER -----
<br /> s # i IT-�-'-':---•-'S'-- r-- ('.r7- "i = �., i �15�� . � jW,_ 'r i j 4i--� ,,- z}I ri + � - ti iw _
<br /> Received eceipt-Noi.-.. 7 ' '---Permit Na'' Oste--'s Mail:. LL_Delivan+rl'i. . •.r f .
<br /> APPLICANT-RETUAN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 1-HAZELTON AVE:P.O.Bos 2009,-.`JSTOCIITON CA 9520'
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