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k .at ... _ ... �, -�, -ate..•.;. u..�.. .-r-:z.�!.f,:}_ ,£P.y:.J.!£ll�y.tK#Fla'..n-1?.tG�.'C`..>n..�fr �.-+4a..�._.. _._"�y NI°>fi.t�r9. � - App.1catlons W19 no nrocesatad Whor"- ---arty Completod.3e st+re To v',.-. -he Appllcafion. FOR OFFICiS.l S .91 Q�d�t� ^, ._ (hof MOA'ranntxrabirs,Ftevxs"+Ie.3uspendable) j - - __ - ----- ENVIRONMENTAL HEALTM PERMIT (TOMiIaLETli IN"^`�'.ICAT'E� WATER QEIALSTY Application is hereby made to the San Joaquin Local Health Ulstrict for a permit to construct and/or install the work herein descriyed.This application is rift made in compliance iiIf: ,�a2Joaquin County Ordinance No.1862 and the rules and r"ulations of the San Josouln Local Health District.°x.9rt Site Address _ „City/Town /i"c - r1 ' /1/:1:+'` Owner's Namey� _ _ --- -_ --- ��=��r-`�,_• Phone_ _.�!.__t�. -. •� ° _. ��; ddress City- ------. - ..---- - Contractor's Name License a_- -_ Business Phone Contractor's Address!. ''� �; _ �<_`� Emergency Phone- __-._----'— - ---- - - - ---- - Certificate of Workman's Compensation !nsurance on File With SJLH09 Yes_-_ No -_- TYPE OF WORK(CHECK): NEW WELL DEEPEN C ❑RECONDITIONDE-STRUCTION+ y'a 'YELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 7 `7EPLACEMENTxf _`IST'ANCE TO NEAREST: Septic Tank �,� Sewer Lines _ Pit Privy Sewage Dispose!,,=field i Cesspool/Seepage Pit __--___ Other__ ;- Prop•. Line Private Domestic Well-___ Public Domestic Well-_-__.___- t �•c- INTENDED USE TYPE OP WELL rf -1 INDUSTR!AL ❑ CABLE TOOL Dia,of Well Excavetion/__�� DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing e. DOMESTIC/PUBLIC 1,l ❑ DRIVEN Gauge of Casing IRRIGATION ! 13GRAVEL PACK. Depth of Grout Seal CATHODIC PROTECTION ROTARY Type of Grout :>-G �'� r;•, DISPOSAL ❑ OTHER Other Information_-^`�-✓_tip /,.�, '. ❑ GEOPHYSICAL Surface Seat installed By: PUMP INSTALLATION: Contractor Type of Pump - - — _-- __ H.P. 'UMP REPLACEMENT- ❑ State Work Done.___.--___ PUMP REPAIR: ❑ State Work Done - DESTRUCTION OF WELL: Well Diameter Approx:matc Depth Describe Material and Procedure I hereby certify that I have prepared this application and that the work wit! be done in accordance wi!ii San Joaquin County ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that in the performrnce of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Cullfurnia.- I� Contractor's hiring or sub-contracting slgna.4ure certifies the following:"I certify that in the performance of the work,for which this h permit is issued. I shall employ persons subject to workman's compensation laws of California.” I will call for a Grout!n. an^ , tlno one a final ln.pe*_tlon. , S'gned �-�'�//,/- ll �-l- Lt _ Title: � �_ ` s (Draw Plot Plan nn Reverse Side) /l FOP. DEPARTMENT USE ONLY i PHASE! ' Application Accepted By ___ -_✓ !`� _ _ y�L - . Additional Comments:----^-----_----. y-- na! - - - Phas 11 Grout Inspection + l j III Fina ns ectfon Inspection By Date _f-` Inspection B .yC ,�i �t i/ i Fee Is Due: ❑ ANNUALLY -_❑ PER-6t�IT ', uEli SITE ❑ [ACP ❑ Januery t at R,�crwr� Ay Jxnuyvy 7t �❑ July 1 N•... ;�,_„131 ._BASE Ek PLA�JA110N i Bit LING REMil'ANGE $ I r+t'V'T // I AMOUN-OUL C`O'CKn ,,. DATt. DATE r1rMIT'ELI rEC 15 1—') y J: LESS i • ' PZiORATION i v r:NAi_'v --