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Appl. ai io ,Mill Be Processed When Submitted.Properly Completed. Be Sure `tea <br /> c USE: ,� <br /> APPLICATION" r`� ��4aC)u <br /> (For Non-Transferable, Revocable,-Suspendable T'UMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 2 A, T/ <br /> j I -7-/ ER QUALITY <br /> ) <br /> (COMPLETE IN TRIPLICATE) <br /> Application ishereby made totheSlanJoaquin Local Health Districtforapermit toconstruct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the..rules and regulations of the San Joaquin Local Health District. <br /> f Exact Site Ad.dress� -I�'~RN� -bT � '� City/Town <br /> �� T Phone q 3 ra - 34 32, <br /> ; Owner's Name j-A 1v �i� N� � Cit J L-row <br /> Address 3rI'7L�' A' 3- '50-o 2 <br /> License# (}� . u ess Phone <br /> f. Contractor's Name <br /> Iy� Emergency Phone <br /> I Contractor's Address 2 !7/ •�lo <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes <br /> TYPE OF WORK (CHECK): t NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> E WELL CHLORINATION E] WELL ABANDONMENT ❑ OTHER C3 PUMP INSTALLATION 13 PUMP REPAIR <br /> REPLACEMENT❑ ' <br /> =DISTANCE TO NEAREST: S]ptic Tank Sewer Lines Pit Privy <br /> r,i Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> P ro perty line Private Domestic Well Public Domestic Well r� <br /> INTENDED USE I <br /> TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing <br /> i ❑ DOMESTIC/PUBLIC <br /> ^^ ❑ DRIVEN Gauge of Casing <br /> " IRRIGATION W ' 13 GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION <br /> ❑ ROTARY Type of Grout �y <br /> ❑ DISPOSAL- ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL is Surface Seal-Installed By: <br /> t PUMP INSTALLATION: Contractor-Al A, K: 1A A <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done { <br /> PUMP REPAIR: <br /> ❑ State Work Donee <br /> Approximate Depth <br /> -DESTRUCTION OF WELL: Well Diameter App <br /> Describe Material and Procedure <br /> ' T I hereby certify that,I have prepared this application and that the work will be done in accordance with San Joaquin County 'r <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> N', Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> become subject to workman' <br /> is issued, I shall not employ any person in such manner as to s compensation laws of California <br /> G <br /> Contractor's hiring yr sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." } <br /> I. <br /> M <br /> I <br /> -c I for a Grout In p prior grow' <br /> Titland a final inspection. <br /> �• i e:-! --- pate: <br /> -- <br /> jl� .Signed X � �- <br /> (Draw Plot Plan on Reverse Side) <br /> _F R DEPA MENT USE ONLY X79 <br /> PHASE I Date �a� Y-71 <br /> epted <br /> Application AccBy `� <br /> Additional Comments: <br /> Phase III Final Inspection <br /> Phase II Grout Inspection Z 7 <br /> Inspection By <br /> II Date Inspection By CGy.--Y Date <br /> Fee IS Due: 13 ANNUALLY� ❑ PER UNIT ❑ PER SITE ElEACH ElJanuary'l &Received By Janu 1 - ❑ July I &ReceiveRdEMIT By July 31 <br /> l BILLING REMITTANCE $ AMOUNT DUE CHECKED � <br /> _ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> tom- A" <br /> FEE IIS <br /> LESS it <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> de y <br /> tear y l��pi'Da1e'° Receipt No. Permit No. Is <br /> to Mailed Delivered <br /> � � - <br /> u _ arar -raMr� t <br /> '~"'oETURN ALL COPIES 70: "'-ENVIRONMENTAL HEALTH.PHRMITISERYICES 160VE:HAZELTUN AVE.,P.O.Box 2409 J STOCKTDN,CA 95207 <br />