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Applicstlons Will Be Processetl When Suhmllted Properly Completed.Ile Sure,To,Sign Tjle Application.
<br /> FOR OFFICE USE APPLICATION ;1-! 7. --
<br /> (For Non.Transler.ble,Re:c•cable.SuspeFdabler
<br /> PL'15P \:'cLL
<br /> CJIENVIRONMrNTAL HEALTH PERMIT
<br /> L—Mpa�CF IN'.glP`ICgTE) WATER:}JALITY
<br /> ApptieahOn,s hen=6y made to toe San Joaquin Local He..Ih Distract Tars perp✓t:-consfrucl and o(,nsf.1,the w oak nere,p Oe.creed This application s
<br /> made In compliar!;e will,S-i.Joaquin Court!/Ordinance No 1462 and Inc '
<br /> .:es ar•0 regulations.pt LnF San Local Heaifr.Ds:nct
<br /> Exact SneAedress 12y70 C. L„IbG Ra• Cry Toil -He
<br /> Owner's Name l,'..5._G137G h}Oy— syNL 7r,ane
<br /> Address
<br /> P-Q:_1)REqi.L;M- N -- r
<br /> Gfy LCL'•K-L FOi.L7
<br /> Contractor's Name C-. 14RIrv& UUII)p License e3o-fv3 I Business Phone-72-7-5548. -"
<br /> Cor,P ctor's Address I� �,.UX 113, 1LY.ILGPC410 Emergent,Phone '72
<br /> Is Certificate Of V/O[Ymd! .,Compensation Insurance on Fde VAth SJLHDn Yes NO
<br /> TYPE OF WORK (CHECK) NEVJ'AELL 11 DEEPENS RECOND,T!ON❑ DESTRUCTION❑
<br /> WELL CHLORINATION O WELL ABANnONMENT ❑ OTHER ❑ PU•AP INSTALLATION❑ PUMP REPAIR
<br /> REPLACEhIENTO
<br /> DISTANCE TO NEAREST Septic Tank Sewer LmOs pit Pr„•,
<br /> Sewage Disposal Fielq• Cesspool Seepage Pa Omer
<br /> Property Line private Domestic Well P,,bl,c Olomcstic well
<br /> INTENDED USE TYPE 00 WELL
<br /> ❑ INDUSTRIAL 13 CABLE TOOL Din of WbP EYCaVai-On
<br /> ❑ OOMESTICIPRIVATE ❑ DRILLED D.a of V:cll Casing
<br /> 13 DOMESTIGPUBLIC ❑ DRIVtN Gauge Of Casing t
<br /> ❑ IRPIGATION ❑ GRAVEL PACK Deptr Of Grovl Sc•al - - - -
<br /> 13 CATHODIC PROTECTION O ROTARY Type of Grout
<br /> ❑ DISPOSAL O OTHEROther Int ormaticn
<br /> 17 GEOPHYSICAL Surface Sea] Instwil By
<br /> PUMP INSTALLATION: (;ontractcr
<br /> ype Of Punlp H P
<br /> PUMP REPLACEIll ❑ Slate Work Done PWT)PPIna iib wI..- 405tr r.ilfu)�igl
<br /> PUMP REPAIR: State Wort Oonef;AjWd`Z-3e np Tn'WIS Z',Y}'ZI)S toll —
<br /> DESTRUCTION OF WELL: Well Diamatcr ApproamateDepth
<br /> Describe M sv+tat and Procedure
<br /> 1 hereby certify it,at I havrt prepared this a On and Ib.'it 149 warn Nall b r'•
<br /> pp!rcab' dine ,n accrtlrncc wdn San Joagtnn Cuvnty
<br /> Ordgdne Cs.sate la.sand awes and fegulatiuns of[lie San JCagum •Ocal Hoal..i D.s!uct
<br /> Homeowner or licensed agent's signature certifies lire following: Icen,fy;ha; nv'••:Le40zrmanre of we rvoa,fonamcn tri%permit
<br /> K iii I:nal!not employ anv person in Such mannef as TO become sLihf'ct td .Or:man s cc moon sd L'.n!,Iws Of Caf.iorma”
<br /> Contractor's hiring orsub-contracting signature certifies the following: le�ro!:ma;,n:i:,.�._,iprmanp.:Ol;n,.:.�rh toa'nhich:', ; �•
<br /> permit,5 si .I Snail employ L,Pasy,hs[ubprcl V; non.r,,an s comr:ensa!Inn l 1WS N Ca'.roam;, 1Z—
<br /> Is,I
<br /> Z—
<br /> IW' 1/�J '/�a,�Grout...Isssnsppection prior to grouting and a fine!InspirOfi n, /!,( •`•
<br /> Signed X ��/-It9i+�.yru-/ Title: �` L.�✓a' / Dafe: '17,fe
<br /> / !Onw Pip!Paan On R ver•.,• y(
<br /> FOR DEPARTMENT USE ONLY '
<br /> PHASEI I & it,Appl.cavon A-s,plej BA7d-!tonal Cumm.nts �nW 1 �'��•tr•c•�va, "r.-. .3l C�,Lu„(fs.f.�1v.��� �� �
<br /> Phase 11 Grout Inspection - D
<br /> or.BYFillDatil Phase III Final Inspection
<br /> Inspect
<br /> Fee Is Doe:❑ 4-.-. ❑ :i:. ❑ n , n -. n :.,
<br /> �i Ir
<br /> i
<br /> 1r•II,C.,rf-YIfVPXPLL CVY,(S10 [•-.Yiupr,VlM1rll rrL.lr•r VLV4.1 St.,CLS I."f M Alall64.iir eV tell T.11 1111.1VN C.Yf]Ci !
<br />
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