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Applications Will 8e Processed When Submitted Properly Completed.Be Sure To Sign The Application.u /` <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application Is hereby made to the San Joaquin Local Health District for a permit to construct and or elstd II ttit!work herem described This application Is <br /> made In compliance with San Joaquin Cuunty OrdLindnce No 1862 and the rules and regulaltons of the Sdn Joaquin Loc I Health Distr,ct <br /> Exact Site Address yr oS /V T�CKTC��r IC� City,Town 15 ?1 <br /> J tv��of <br /> Owner's Name /'M1. G. /—QC/�jvY CJ Phone <br /> Address Sim e City <br /> Contractors Name A•/Y, 0-, "It, License« Liy Business Phone 7.1.3= j11-y <br /> Contractor's Address ,y/� Gli`OCi.1r� ,$f �i-r<l�� Emergency Phone �'l�S�'JSyl <br /> Is Certificate of Workman's CompensationInst one con File With SJLHD? Yes No <br /> TYPE OF WORK(CHECKI NEW WELL DEEPEN❑ RECONDITION 13 DESTRUCTION❑ C) <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ J <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST Septic Tank .�4"Y./$ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other /'I'st"V <br /> Property Line /r/ Prlvala Domestic We11 Public Dume4hc Wen <br /> ENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia of Well Casing fr+ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Cutting lC fc .�C'L A", /a�( <br /> ❑ IRRIGATION Q GRAVEL PACK Depth of Grout Sedt <br /> ❑ CATHODIC PROTECTION C1 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ UTHER Other Inlurinatlun <br /> ❑ GEOPHYSICAL Surface;ieal Inslnllud By /},/7, ��pyu C✓<� �,���� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H t' <br /> PUMP REPLACEMENT: ❑ Slate Work Done <br /> PUMP REPAIR: ❑ Slate Work Dune <br /> DESTRUCTION OF WELL: Well Drarnetor Appru.eo.th+Duplh O <br /> Describe Material and Procedure <br /> I henlby certify that I have Weparod this application slid that the work will tilt(tune ni accuh.laNco*1111 San Judquel Cuuhly <br /> oidin.Irlces. stale t,Iws and ruins and mpulnborls of Ihe'inh Joaquin Local 1044th titsiticl y <br /> Homeowner or licensed agent's signature codifies the following:'l testily that ill the perfunnahcn ill ihP work fur which this Iwrmtt <br /> s issued. I shall not employ any Iverson In such manner as 10 become subject to workman s cumpl•hnalwn laws of Callfurnla' <br /> Contractor's hiring or sub-contracting signature etortiltes the following;"1 wilily that In flit,lit"Iminar,t v til the wotk lilt which Ih,s <br /> permit is r.c,t,cd I !.hAll t'rnploy pursorrs sutilect lu wont-116111%t.onytansation Is*%Of C0111hrnta <br /> I will call for a Grout inspection prior to grouting and a lit I inspection <br /> Signed X v 1(��'K:1-� Tills: /1� Dale: / <br /> (D(aw Plot Plan un Never,a!;Idu) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Apphcahon Act:uptc4 13y <br /> Additional Comments <br /> Phase 11 Grout Inspection Phase 111 FH%11 Inspection <br /> i Inspection By Date Inspection ItY ''• r- .L +. Udle <br /> Fee Is Duo: ❑ AV. , ❑ 1'l 11 t1N,: ❑ Pt -,I It ❑i m•i �.^.l <br /> ❑ JIILUAIY 1 A ltii,„�i, 7+ r•17 �.,i, 1 6,lot o..eJ b, I.,r N <br /> lilt LINt1 Tit kill IANCt MEWT <br /> I Ix/'t ANA1ION No,(tAll <br /> DATE ,UMi11Itt AMUUNI t1Ul CMtCrt(p <br /> AMOUNT <br /> ICE Lim/ <br /> tEt:S <br /> PRt IIAII0N <br /> 1'tLJ <br /> I't NAt.TY <br /> Will.It <br /> j ;,trq it 1 ' <br /> ..0. N., <br /> M'PUl'AN1 Nt 1l1NN All COP11.1 10 I NVnitINAIt NTAL WAt IN PII/Mil tLNVIIts 1401 1 NAlELTUN AVE P so.Sour 4focxTON.CA ft"I <br />