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.T , .;,•'r Applications Will Be Processed When Submitted Properly Completed.Be sure f o sign r n`vim---...r <br /> FO FIAPPLICATION <br /> ,CE USE: b� <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ` WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fore permit to construct and/or install the work herein described.This application is <br /> and the rules and regulations of the San-Joaquin Local Health District. <br /> made in compliance with San Joaquin County Ordinance No. 1862 lY <br /> �_—��� City/Town <br /> Exact Site Address <br /> ' Phone S— <br /> Owner's Name r Cify <br /> Address ' �7 �l�J �j � <br /> ContractoName LicenseAl'•J� Busine Phone <br /> r's .(n <br /> �C� / <br /> Contractor's Address <br /> s.•r.t�.®rikf Emergency Phone �— <br /> �%�"� �—� <br /> Is Certificate of Workman's Compensetion Insurance on File Wit n SJL • K HD? Yes XNo� <br /> 'TYPE OFJWORK (CHECK): NEW WELL 'DEEPEN ❑ RECONDITION 0I • DESTRUCTION[] <br /> WELL 'CHLORI NATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION SUMP REPAIR❑\ <br /> REPLACEMENT❑ Pit Privy \ ,. <br /> DISTANCE TO NEAREST: Septic Tank / O� — SSewer Lines <br /> Cess ool/Seepage Pit Other <br /> Sewage Disposal Field P <br /> d Private Public Domestic Well <br /> Property Line <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia•:of Well Excavation <br /> ! ❑ INDUSTRIAL <br /> OMESTIC/PRIVATE El DRILLED Die. of Well Casing _ <br /> 11DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing O <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> � ❑ CATHODIC PROTECTION <br /> 5'FTOTARY Type of Grout <br /> ❑ DISPOSAL a ❑ OTHER Other information <br /> ❑ AL Sur al Inst Ile�d B <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done . a <br /> PUMP REPAIR: ❑ State Work Done - - <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter r <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the perform an tem the work forwhich California.' <br /> I issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or 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 will 11 for a Grout Inspection Prior to gT uting and a final Inspection. 1 d 7 <br /> ./�} .r ,`f�`w-- Title: Date: <br /> 1 Signad X iY �-•� (Draw Plot Plan on Reverse Side) <br /> tF �r <br /> FOR DEPARTMENT USE ONLY J <br /> PHASE I Dat9/4---i-R—`—� <br /> Application Accepted B ' <br /> Additional Comments: <br /> as 11 Grout Ins action pix Final In �ecllon <br /> t /�p ate / 2 Inspection B d 1"�h'� Date <br /> It Inspection By 111 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveddEByl July 31 <br /> 1 NATION BILLING REMITTANCE $ AMOUNTOUE CHECKED <br /> BASE EXPLANATION 1 DATE DATE REMITTED AMOUNT <br /> FEE s 2 p r <br /> LESS <br /> PRORATION <br /> C PLUS <br /> [ PENALTY <br /> OTHER _ <br /> t „ <br /> OTHER <br /> ate Receipt No. ,, y I suanc Date <br /> Permit No <br /> - Melletl Deliveree <br /> .—i—A by �........� en u...va" %Ter:KTON CA 95201—� <br />