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<br /> Appl{celionx WIII Be F'ro, eo Properly Completed Be Sufr Tr, '• I',.Appllcihnn •,I
<br /> 1�PP RATION
<br /> 1 OFFICE USE:
<br /> — —� EN'JIPONI,11_fRTAi, H ALTi: PERMIT
<br /> WVER IpUPAITY , tv e—,,; '
<br />�LETE IN TRIPLICATE) 10 1 '
<br />::t,nnIshernbymadetothe SanJ •
<br /> nlot ,1•'nl, I^"T'- CCiI%Irvc n ,r✓ '
<br /> n :ornphance with San JnaOu,n Cnunly r; '• / and r,,gala',,ins.,! ,r ,•.l.:.n Lnr.a rt' , ,�-j .
<br /> ;,In Address C i)11�7t
<br /> �
<br /> ss 1_In9V ! (20 /�>•�7 CY_. ! r 1 City
<br /> Tctor's Name
<br /> I-/ NUL' nncnx BIISIneS.. �`:ii
<br /> A! F
<br /> It-4
<br /> r-, � �3/`/( •�— ' � F'.,
<br /> �'vr./)••/' '( :mnrpr•ncY Dhone
<br /> hrtor'sAcldress J/.3t� N � •.�
<br /> 1)ficale of Workman 9 Compensation In,uranr.r•,,i' t !' ,'• '^ ' 't"r)� V^s X
<br /> OF WORK (CHECK). NEW WELL'N DE[r I r.; T) •'ECONDITION❑ DESTRI '-'':i'+ 1
<br /> c T! PUMP PEPAIP❑ —L "E'
<br /> CHLORINATION E3WFLL ABANDONME rl T C1 ;:T HER 13 PUMP IN. LAy;:
<br /> ACEMENT❑
<br />',NCC TO NEAREST. Septic Tank ! n, Pit Pr vy
<br /> Sev. qc Disposal FI Ill, p P Qe Pit C'nr'r
<br /> Property Line /'watt !` •r,.stn:Vti Pit Public DorI V."I
<br /> NTENDED USE TYPE OF WELT. r�
<br /> IDUs TRIAL ❑ CABLE TOO' Jla'." ter
<br /> � a«
<br /> OMESTIC/PRIVATE ❑ DRILLEf' a na
<br /> OMESTIC/PUBLIC ❑ DRI,'N Gauge of Casing
<br /> IRIGATION ❑ >1AV[-_I_ F.,,K Depth of Grout Seal
<br /> h•p,".,?Iii
<br /> ATHODIC PROTECTION ❑ 107 ARV Type of Grout
<br /> t
<br /> ISPOSAL ❑ Other Information
<br /> EOPHYSICAL Surlace,Seal Inst/J d By y ��
<br />-P INSTALLATION: Contractor L f1
<br /> l 1a .
<br /> Type of DIImp r 7��JJ.1�t�'L.,Zl,F2(LC.- H P
<br /> IP REPLACEMENT: ❑ State Work Done —._—_---- ------- `
<br />,P REPAIR: ❑ :�ta!`'r',,K Done e
<br /> TRUCTION OF WELL: 1', '! Dcu, ter Approximate Depth
<br /> M.Heiiai,wd I'mcedure
<br /> I hereby,certify that I have p•epare,, this application and that the work will be done in accordance with San.loaquin County r
<br /> ordinances,state laws.and rules ane'regulations of the San Joaquin Local Health District.
<br /> Home owner of licensed agent's signature certifies the following:"I certify that in the performance of the work for which this pr rmit
<br /> is issued. I shah not employ any person in such mat n: as;o bec'me subject to workman's compensation laws of Califnrr•ia."
<br /> Contractor's hiring or subcontracting signature certifies the following:"I Certify that In the perlotrnanco of the work for whl,:h;his I
<br /> permit is issued.I shall employ persons subject to .).:'kman's Compensation laws of California."
<br /> I will call fora Grout Inspection prior to ro•ilin7 and a linatclion.
<br /> X� peL(C/C. Title
<br /> � t Date:
<br /> Ted
<br /> �.
<br /> (Draw' ',)t P!nn on Reverse Side) ,
<br /> W FOR DEPARTMENT USE ONLY
<br /> PHASE I
<br /> Application Accepted By — (r
<br /> Additional Comments: .-_�--- -- —' "— -- —
<br /> Phase 11 Grout Inspection PhesfA/III Final Inspection a
<br /> Date Inspection BY %F'—�'/'/)----- Dwe �, f__,7-E i„
<br /> Inspection By--—--- - `'��c•«- � ,� .
<br /> Fee b Due:❑ ANNI IAL LY ❑ PER UNIT ❑ 1'rP•,!t I ❑ f ACH Cl .Innuary 1 dFrcevna nv
<br /> gEMI I
<br /> IIILI ING IIER7!1 T' 'CE S AMOUNT DUE C,tiCKED
<br /> BASE I EXPLANATION (IATr I DATE_ REMIT,FD A-.4 N7
<br /> FEE
<br /> !
<br /> LESS
<br /> �'•'
<br /> PRORATION I - ,r -q
<br /> Plus --- - j gjjs
<br /> PENALTY
<br /> OTI4ER
<br /> k
<br /> 010 l`-{----- —
<br /> Ppumt N•r If«uenrr[).l b, Mailed ti,•�'.,",•A I
<br /> Hnr,1,wM by Dia,, nr.nnq hi,
<br /> APPLICANT—RETURN ALL COPIES TO: rNVIRONMENTAL Itr At it P,npwrisrvivicEs 1,101[.NA2EliON AVr..P.O.a02 IM STOC«iON.
<br />
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