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t � <br /> \.Ol <br /> Applications Will Be Processed When Suhmitled Properly Completed.qe Sure To Sign The Application. <br /> FFO�OF l USE APPLICATION <br /> - (For Non-Transler.ble,Re:ncaole,SuspeGdalile) i <br /> PLlPLP r <br /> ENVIRONMCINTD.L HEALTH PERMIT <br /> (COMPLETF IN.RIPLICATE) WATER JPALITY 1 <br /> Application is hereby made to the San Joaquin Local He,..th District lora Perm.'!- _onstrucl and'co3 sfall the work hpreip descriifbed This application is <br /> made m compliance wi'h Sir J6aquln COumy Ordinance No 1562 ani me :u:cs and regulations pl me.bqn Joaquin Locdl hearth District. <br /> Exact Site Address 1ZIJ-10 1•. LCL Ra, Co, Town- '- <br /> Owner's Name L'.S• GIaSc)r+0L— a Xfi Pr)nn _ <br /> Address-T",v oklgh. .)Ei2 N Ca, L4=fCK-C-P0i2a l <br /> Contractor's Name C',C;iCµRINC0 Pump License. 5 r' <br /> �C.Y-1031 Business Pnone�,�7-5-.) TS <br /> ` <br /> Cour ctor's Addtess-l--,>, 130K 113, LCx Lapcl20 Emergencv Phone <br /> IS Cerbhcatq ul Workmai ,Compensation Insurance on F.ic With SJLHD9 Yes No <br /> TYPE OF WORK(CHECK). NEW'NELL❑ DEEPEN 13 RECONDITION[] DESTRUCTION❑ <br /> WELL CHLORINATION❑ WLLL ABANDONMENT 13 OTHER 1❑ PUMP INSTALLATION❑ PUMP REPAIR � <br /> REPLACEMENTO 2 PTS <br /> DISTANCE TO NEAREST Septic Tank Sewer Unes Pit Pov�i <br /> Sewage Disposal Field Cesspool Seepage Pit One, <br /> Properly Line Private Domestic Well PubhC Domestic V:ell <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CARLE TOOL Dia of Well Excavation <br /> 17 DOMESTIC,PRIVATE ❑ DR'LLED Dia of Well Casing _ <br /> 17 DOMESTIGPUSLIC ❑ DRIV,If Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Deptr of Grout Sett <br /> 0 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 17 GEOPHYSICAL Surface Seat Installed By <br /> PUMP INSTALLATION: GonlractOr _ <br /> ype of Pump H <br /> PUMP REPLACEMEI.T: ❑ Slate Work Done KUnPs"I -154:fiwrbine.-nCWkXwb 4`405t.zif"lon <br /> PUMP REPAIR: 1] Slate Work OoneMU11Ptt2--3C nP}UMLr)C'- t�L'K'0r W15 + ZO S'f. LYI'ension — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> J <br /> Uesenbe Mit,nal and Proeeduec <br /> I hereby Certify that I have prepared this apPhca Von and Ihat one work will be done in aec,-dance with San Joaquin County <br /> om-nances.stale laws.and w.es and fegufaiioh5 0 the San Joaquin i.ocal HeaLo District <br /> Home owner or licensed agent's signature certifies the following: I certify that m the perlororanre of the work for wmcn ttua permit <br /> is Kstiad I Snail not employ anv person in such manner as to become subject to workman's COMOOnsa Win laws of California" <br /> Contractors hiringor sub-contracting signature certifies the following: is-atdv tnatmtil2 t rmanc2 of ilio work 1prwh¢hL <br /> 9 9 per o tis <br /> permit's ss, ,1 shall employ pers,ns-.,poet!in Wormian s compOn S.d Wn laws or Calif lrnuT <br /> 1 w 1 a G�jifut Inspection prior to grouting and a lin-.!inspect n. <br /> A. <br /> Signed y�/Gr//.'N'N'' Title: Dale: <br /> (Draw Plot Plan on R eer5n r !W ri <br /> FOR DEPARTMENT USE ONLY _ - i 1 <br /> PHASE <br /> Application A,;epled By `\ • ' 1 <br /> Add tiunal Crihm>ms {�U <br /> `Rrv++ "'^.•• , e �06L li <br /> Phase II Groul Inspection Phase II7,ui Final <br /> prec`tiWon,D�ate <br /> D' <br /> t•`` ``dam <br /> Inspec h,.,i.By 1' ` '(D,,— Dab. ,p¢i lir isi- -. - i Gate <br /> Fee Is Due ❑ .... .. ❑ ❑ : ❑ - [i ❑ L .., <br /> Era- <br /> " ECMO <br /> '1717 <br /> Lf- <br /> nl V`. <br /> �� APPLiCAf4t- AFIVPMALLCVP415TO f,,Vulal YrM1flit IaALTn r,{XM•15rkV,CtS "I'E MAlt,IVN Avi VI', a-MUY SICCxlo. C1 I'll, __ _ .A <br />