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%to. Applicabohs Will Be.Promssed When SLbmtlled Properly Completed.Be Sure To Sign The Application. 06 APPLICATION �n _ (For Non-lornsterable.Revocabh:.Suspendable) PUMP&WELL or•7. - ,.-.ENVIRONMENTAL HEALTH PERMIT (COMPLETE IN TRIPLICATE) WATER QUALITY Application i•hereb-mace to!he San tuPw+r;LOca1 k'^allh Dlsotcj fnr a permit to cor SlruCt an0'Or mSall the work herein descnbee This appit"tiOn Is made in compliance with San.)"qu a,noum rjrO.nanc.`No. 1662 an.:me rules and regulations O':he San Joaquin Local Health District. Exact Site Address �[ - ,/i i i' City Town > /C Prom, 3cOwner's Name C.'.2 1i11__ r c�^^yam 1 ( _ - ..1 Address City rffC Contractors Name Name /&:_..ri �!- �'-C �•rJ License a (.(/( BUSi".SS PhoneConti actors Address /•: L % %V - Emergnncv Phone - - -----—----I Is Certificate Of WorkmanYl C '5 Compensation Insurance on Pile Yl Yes No r TYPE OF WORK(CHECK) NEW WELL DEEPEN ❑ RECONDIT.CND DES7RUCTION0 WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR REPLACEMENT O D STAk:CE TO NEARESTSeptic Tank Sewer Lines Pit Pr" Sewage Disposal Field Ce$SOCOI/Seepage Pit Other ... —. .-- Properly Line Private Domestic Well PUD,c:Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation ---- ❑ DOMESTICrPRIVATE CJ DRILLED Dia. of Well Casing - _ --. ---- - ❑ DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _.— _-- - ----------- CATHODIC PROTECTION ❑ ROTARY Type of Grout - - - -- - ------ ---/� ❑ DISPOSAL O OTHER Over Information 13 GEOPHYSICAL f' Surface Seal Installed BY: PUMP INSTALLATION: Contractor._. . 11 /' r• 7' C. . - - -- /l �'�/, ----- Type OI Pump ._. eC.+.-r _ _. HP- PUMP REPLACEMENT: O State Work Done PUMP REPAIR: 0 State Work Dole lqET-1rQ.Lv4- o+o•L,'�a...L - '- - —— DESTRUCTION OF WELL: Wen Diameter ApDrox,mAle Depth --- - Describe Material and ProcedurC _ - - ------ - - -- '- I hereby Certify ilial I have prepared this ElDplicallon and that the work Will be done in accohlancu with San Joil County ca ordinances.State lAwl. 'I'd rules and regulations of the San Joaquin Local kleagh District. Homeowner or licensed agents signature certifies the following: 'Iceru!ylhatmihepdrIOM3a ceuf U. r0or•N icbthi5permii s issued I Sha!l not Pmoloy any person in such marine,a5 to become subject 10 woixman S Compo'-AL n 1;.ws of California." Contractor's hirlr 8 Or sub-contracting signature ceelifies the following:"I Certify that in the performance of the work to-which this permit Is issued. I shall employ Persons SUbleci to workman's compensation laws 01 CAIdOrnla I Willis forfa Gro speclian prior to growling and a final Inspection Sign X � / 2_,r f , Title: � .�.-r�[�L/ Dale: g v PIOt Plan On RevCrSC idel FO�.OEPARR,TMENT OF ONLY PHASE) nT /J /j�nJ Date /3P P-1 ApObcallon Acceptn By Add"IOnal COm^Iwn:s Phase 11 GroutInspectionPhase III Final inspection InspPGbon 8': Cate Insoect.., By Date Fee Is Due: O - . :A_r. ❑ :.r:: .. . ❑ .•r;, •r .. r 1>v " p O , + 5 a......, qr�.^P.1,r O.iia, + a n.. .•a Dv J•11I. .. RE%,,- L N1, qE:. ..NCL E OUNT DUE CHECKED yA.E _ ...•i9a ... . Cn'E Nr;.�.cFD MI AUOV14T —� L_ ..11C.l T-.CTUNN ALL COMES Td [NV:RONNFIIT1l NEA1111 PTPMIT SEAVInCS 601E 11ATFLTgN AYE 00 aOr]0a9 STOGtTON CA 95]01