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v <br /> 71S- <br /> Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. <br /> FC P OFNCE USZ: APPLICATION <br /> l (For Non-Transferable,Revocable. Suspenoable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to Construct and or install the <br /> the work herein described This applicatio'.is <br /> made in compliance with San <br /> Soan JoagUln County Ordinance No 1862 and the rules and regulations,' the San Joaquin Local HealthC�D District <br /> Exact Site Address <br /> ,��/�D //S N �1r�RY 99 City%Town /�C/�1H�G --- <br /> Ownprs Name p IVS-L E�E55/ Phone 3 3 4 - 3 7 Sin <br /> Address /D 9/5 /S/ /�/Wi¢�/ -9y City i �� C�' <br /> Contractor's Name t�1 �_iPJL.L/�N�(�J. License a 337o��BUslness Phone 75�— 33 7 7/ <br /> Contractors Address ?4�X� ./E.V7S C X27 Emergency Phone �5�- �`f S✓is Certificate of Workman s Compensation Insurancecl on File66 <br /> Ith SJLHD? Yes x No <br /> TYPE OF WORK (CHECK). NEW WELL 13 DEEPEN ❑ RECONDITIONX DESTRUCTION❑ �rJ <br /> WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> RLPLACEMENT❑ <br /> DISTANCE TO NEAREST Septic Tank /!jGSewer Lines X50/r Pit Privy <br /> Sewage Disposal Feld - Cesspool/Seepage Pit Other - <br /> Property Line .25' Private Domestic Well �� Public Domestic Well <br /> INTENDED USE 11.�1t TYPE OF WELL <br /> ❑ INDUSTRIAL Jot CABLE TOOL Dia of Well Excavation <br /> ❑ DOMESTIC PRIVATE ❑ DRILLED D'a of Well Casing <br /> ❑ DOMESTIC PUBLIC ❑ DRIVEN Gauge of Casing <br /> JM IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information - <br /> ❑ GEOPHYSICAL r^ Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> HIP <br /> PUMP REPLACEMENT: ❑ State Work Done T <br /> PUMP REPAIR: 1377 <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Doscr.be Maters-i and Procedure —y <br /> I hereby certtty that I have prepared this appllLation and that the work wilt be done ,n accord[.nce with San,oaquin County <br /> ordinances.State laws,and rules and regulations of the San Joaquin Local Health District r. <br /> Home owner or licensed sgenl's signature certifies the following: I rerldy that in t -pe•formance of,hp work}:,r which th'S p.+rmlt <br /> is issued. 1 shall not employ any pers,)n in such manner as to t'ecorne subject to workman S comp#7nsatlon laws of California .T <br /> Contractor's hiring or sub-contracting signature Certifies the following: 'I Certify that in the pr rformancp int the work for which this —_ <br /> permit is issued I shall employ persons s-lhlect to ,vorkman c compensation laws of California <br /> I will all for a r ,y� pection prior to grouting and a final inspection. <br /> Signed X C• t�-�`-�'�-- Title: Date: <br /> )Draw Plot Plan on Reverse S,dei <br /> FOR DFPARTMENT USE ONLY <br /> 1 <br /> PHASE 1 t �I <br /> Appf cation Accepted By Date / I l J <br /> _a <br /> Ad-lrtional Comments �•/'�t/• � / i` t' / - r , <br /> Phase It Grput IrSspeehon <br /> III Final Inspection <br /> r <br /> Inspection By / /'. Date Insper:liar' B. '�. S O),tr , ,i •�rl <br /> Fee tsDue' ❑ . .. e. (_-1 w,• ❑ rru ❑ ,, .. ❑ �.. �.r ❑ L, ,inn ,. . th, ,. <br /> AM )UNT <br /> {IA f •t' n•.Ar .•� n'1 ,,• it 'A•: ' { p�, l f,1.!:rF F: <br /> ,,c ' <br /> I <br /> .. .. i I....r ,r• fir, • <br />