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<br /> W."P4 I INV^PFn1Cf1flOF6
<br /> FOR OFFICE USE 'APPLJCAT-ION,
<br /> :+.(Far Non Trensferable,ftevoeable,Suspendable)
<br /> ENVIRONMENTAL IdEAtTH PERMIT 7
<br /> (COMPLETE IN.TRfPLICATE)y' = "' F +` ti.w wayin QUAwy
<br /> ;ru Applicatioraisllerebymadet
<br /> *the San Joaquin LwalHeaJ[h'DIStrietfar.aperMRt0Vloos#WCIaad/arinstall.tbework herein describeil,•:This:application�is -
<br /> made in compliance with San Joaquin-County'Ordirlanee ND.1862 and.1ho-jules.q[td*Qulations Of.tkae Sar1:.Jo uLocal-Health.DlsWct-. -'
<br /> Exact.Slte:Address �j '�,j ��• �� � �. �j�� Ctrl,
<br /> Owner's Name ,amilg f96&F_S .�1��3 �(�� Qx
<br /> .Address Phone J
<br /> City
<br /> Contractal,'s-lame �sY• baa ;i, :. - ,�, '--
<br /> I -:Cogtractor s dC ss_►jY` ;.� �. /fid f. Licens9 fR Y �yglne
<br /> Asf e. ; - -_ mercJ+3�cy.Ph.vne
<br /> Is Certificate of.,Workrttan's,Compensatiom Insurance-dh"Fft Wlth'SJklJID?:.
<br /> TYPE"OE WORK(r_HECky. NEW WELL W" DEEPEENZ-2- RECtIOND1TION 0 * :I3EST13L3C CT - '�
<br /> WELL _;,WELE•:,ABAI40ONfu1EIVT Q, " ®THER''© : P.IJiVIP"ulAiS7ALt11TI:DR1 . if`i+��il?f:JMP••tR1=P�Alf�� -
<br /> REPLACEtIIENT O 4
<br /> DISTANCE TO NEAREST:'>..;Septio Tank,'_- „ '' �. :1•:_: 140
<br /> Sewer tfftes + pit Privy ... ^^
<br /> 1,.9ewage_�isposal"'Fleid GeseppgffSeepage reit Other
<br /> ?Rtpperty Line Pdvate Domestle Well. _"_ Yii?ablic'Domestic Well _
<br /> INTENDEDiUSE TYPE"OF'WELL ✓'� :r
<br /> ❑.INDUSTRIAL
<br /> CABLE TOOL 131a,of Well Excavation '
<br /> �7DME5TIC/PRIVA*E Y." : : .:: ❑ 'DRILLED_ .,C :� " X18, of Well Casing- +•
<br /> DOMESTIClPUBLIC• 13—DRIVEN :_.,:.. �.. -Gouge of Casing 146 ;] RVCr.
<br /> �:iRRlG�ITIOt+i, -"❑ -GRAVEL PACK:. w:.,� _. Depth:of Grout Sea[. r -`
<br /> :s•p CATHOQtC-PROTECT,ION: �. "0f'4OTAFIY':-,w . . Type of Grant
<br /> +'❑ DISPOSAL s _ Ll'OT14ER13 Qther,Iniormatian
<br /> GEOPLiYSiCiaL -- Surface Seal.installes1,gy
<br /> PUMPANST.AL:LATIQN «: Contractor- 4r1
<br /> -•:� rae� ;, .. Type Of Pump
<br /> H.P.
<br /> Pk1NtP RE3i'l ACEII}IE.@I7i. "..: x Y_ _. .n "Stats:Work QoP9 - err- s = 3•s.+�ol ,,r .i,�,. _c�i r.
<br /> "PUMP REPAIR::'.-P.,,;t ,
<br /> 5tate..WnrksDdl�t:�ss—� - .�. .- � ka F =� <,.r, • I
<br /> °DESTRUCTIOWOF WELL.. F.�' :,WelI Diameter: _ w Approxt�rnate.Depth.;
<br /> DesFribp Material_@tad Procedure s
<br /> JV.A`Al 1:hereby eertifythat I.have prepavaddhis,application-and that the,Work,wilt+bedone-in accordance"With San JoaquinOguntyK,� �� f
<br /> �•r,; " : u ,ardinancas.state laws,and mutes and regulations of-the Sart Joaquln Local,l-lealth.District: ^cal in;r.?,:« •:.,�,. 1
<br /> Ss%.tl++f�,v.3:: #iA�tatirtte�for,vicenited;e�gerit�d;Gigneturs:cerlifie6l@►e,tCNstwhlg:w`IcBrtlllnthatie►.tt►spar{OfmaftcB.�fi#1e.wOrk�faralvl�sryhespsrmit';�•a,r,-,,:�<a ''.. ii .
<br /> is.issuedlA'shatf not employ any person in such manneras to,beeorno.subject to workman's.compensation lawsai;California.". 't.,;
<br /> =:=w,r.:. �3>�; �onlcac otos airing or sub sogtr8c11ngrBignstarecrrtifiaslha.iM{ovlrinq:;f¢erti.fy:that in the periormameeai:thgyvn'rk4a*vd.weh•ihis.
<br /> r :.s.0-4wrnit,is issued,4 shall employ parsons subjieat;to workman's compensation laws of Ca_tifarniaio, ,•. :,r�:., '.-;
<br /> aa#3#,win=gatk4or.a MRE6V
<br /> ion•prier'lo;�1 lung;and a•final ins ection.-P Signed- atal,�""+ / ;�`"•_" .�
<br /> µ (Draw Plot..Plan on Reverse Side) - •- �i -
<br /> .- : :, ,. :;'E4+:• :,. :_ FORD PARTME T USE ONLY --
<br /> PHASE I
<br /> _.Applitati=Accepted By
<br /> u ditio s / +
<br /> Ad r3al CaMMBnts: �... . r 41A
<br /> :w�: •_. Phase 11 Grout Inspection T7 ,` Phe 111 final hasps+ w
<br /> InsRec o Cy Date .--- ction.%_ a
<br /> tin r,
<br /> rtepection$Y— .� Date
<br /> gFee�F6sD e:❑ ANIMLJAtLY .•. 0 PER UNIT ❑ PER SITE •,t,x'D;EACH io January 1 b ReceiveA By Janttery3T. Q Jury 1 d ReceiveC By,lulya'L'
<br /> +� BIDING ".flEMITTANCE REMIT
<br /> aASE EXPLANATION S ' AMOUNT DUE '•':"CHECKED
<br /> DATE DATE REMITTED AMOUNT
<br /> FEE ��•� �� -.
<br /> LESS —
<br /> PRORATION
<br /> PLUS
<br /> PENALTY
<br /> OTHER
<br /> OTHEn
<br /> 222 6< I Y�
<br /> Received by Date i, ReCsqA No. Permit No. faswance Date Maly NHered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E_HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201
<br /> I I
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