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Apt.1collons WN Be Prooesfed Nihon Submltled Properly Completed.Be Sure To Sign The Application. sOR OFFICE USE: APPLICATION .� 1 (�!I ` -jhkNcn•Transferable.Revocable.Suspendable) P'11ll'?,WELL ENVIRONMENTAL HEALTH PERMIT A7 `' !'1 .Rt WATER QUALITY 10MPLETE IN TRIPLICATE) -t•. -_ ra 'Ahnn Is horeby made to the�.in.I�:1�uin L'6�a1 H011 t District for a permit to construct and'or install the work herein described.This application is -,+—n compliance wi h San Jp+gwnAounly Ordinance No 1862 and the rules and r%ulat ons of the Son ifoaquin Local Health District. Y -� _.-l+lL�rY:L—=3�- S.tce, /✓ 'v", I `i City/Town ,4CC�C+�1'] ,art $le Addre ._ Iss 1 �.,y� --- - wnrr s Name/�'-' l` I 1 QT``tom ^ UL 1 Phone Y^.cess 3C'I /1tl I P1"Cl_ CtlY A onhactors Name (1•16CA)li(10 ��e- Licenses 3'1'�C'IGO Business Phone Ie3 ".ILL3�I-- - - _116 ontractors Address 211'1 H 3f\f T, ">—n It E. '��, Emergency PCone 41D3-1,424'. Certificate of Workmaiia Compensation Insurance on File With SJLHD1 Yes -\ No 1 YPE OF WORK ICHECKI NEW WELL DEEPEN❑ RECONDITIONO DESTRUCTION❑ 'ELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR EPLACEMENT❑ ISTANCE TO NEAREST Septic Tank Sewer Lines Pit Privy Sewage Disposal Field Cesspool'Seepage Pit _ Other _-__— ---- - -- Property Line Private Domestic Well Public Domestic Well INTENDED USE TYPE OF WELL 7 INDUSTRIAL ❑ CABLE TOOL Dia of Well Excavation �DOMESTIC/PRIVATE 0 DRILLED Dia of Well Casing 1 DOMESTICIPUBLIC ❑ DRIVEN Gauge of Casing IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1 CATHODIC PROTECTION ❑ ROTARY Type of Grout _ _ I DISPOSAL 17 OTHER Other Information. 7 GEOPHYSICAL Surface Seal Installed By 'UMP INSTALLATION: Contractor_ hick(-Ilia- n •-1')CL- Type ofPump �S /j ^ -�A- A H.P /j � ' 'UMP REPLACEMENT: F State Work Done Yrµl/4• o� �Tf] [_�j+7/J_/,�_i_r'p' 6,//_l SUMP REPAIR: 0 State Work Done IESTRUCTION OF WELL: Well Diameter 't oroaimate Depth Describe Material and Procedure _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqum County k ordinances.slate laws.And rules and regulations of the San Joaquin Local Health District Home owner or licensed agenfs signature"IfIKIN IM following: 'I certify that in the performance of the work for which this Permit Is issued. I shall not employ Ar y person in such manner as to beCPrnP sUDfe01 f0 workman compensation lewd Of California N Cenfrxclors hiring or subconineling slgnaluroprblleethe lbllowli I certify that in the performanceol lhework forwhichihis q permit IS Bsuetl. 1 shall emplpy pipn1 sub ect to workman's compensation laws of California" I, for a Orout Inspec dot 1 routing ■final Inspection. M :Igned X —� Title: Onto: iDraw of Plan on Reverse Side) 7I-- ) Q FOR DEPARTMENT USE ONLY l PHASE I ` 3- APPlicabCn Accepted B O,,'hNa- \ Dain \\� Additional COmmerits c - P(hosse II Grout Inspection Phase 111 Final lnapecKon �; Inspection BY 1 I/Q.� Date Insoechon By �' .w Date ❑ A'.'[•fn•.IrF ❑ 1 E3 . \nr,. I� rH 13Ai1i"Jin.]i FN 11 DW: ❑ ANM;A,. ❑ '" i REMIT RULING 111M r•ANIA S AMOUNT Did cHECAEb tin r a eNr �i VA,r t,Aa ni•A'^i li AMOUNT .unnA•i:., ri ur. f YA.,•. .._ Arr'l it AM♦ Af♦ liaM Aii r'1'. 'VYenNMFNTAI MIaITM NRYIr 5(RYICIi IM, r HA?F1Tn1qtAYI en enr JAA TTOCx\niv C111M'