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Applications Will Be Processod When Submitted Prop"Completed.Be Sure To Sign The Applic FOR-OFFIC E usE APPLICATION (For Non-Transfarable,Revocable,Suspendoble) PUMP&WELL '- _�_ ENVIRONMENTAL HEA!TH PERMIT y (COMPLETE IN TRIPLICATE) WATER QUAUff Application is hereby made to the San Joaquin Local rlealth District for a permit to construct andror install the work terein de: ?d.This application is made in compliance San oaqu�1I County Ordi T e No.1862 and the rules and regulations o!the San Joaquin Local Health District � ann��l�ccc,, 5-kckoa__ — Exact Site Address �+`�'_CJJ._ wrs - .•.-- ----- City/Town_ r� � i �C� ------ - Phone Address - Owner's Name �LCr3 T�1Q�� . _ _ _ City-S-1� Contractor s Name Se-fmck• 1t� Gfi71P. M License s 34 aft4O_Business Pho.ve a��i�+ Contractors Address - - 0 � 1 Emergency Pnnne Is Certificate Of Workman's Compensation Insurance on File With SJLHO? Yes _ NO - TYPE OF WORK(CHECK): NB WELLM G;:EPEn❑ RECONDITION 13 DESTRUCTION C3 WELL CHLORINATION[3 WELL ABANDONMEN"1*'' OTHER C3 PUMP INSTALLATION(3PUMP REPAIR❑ REPLACEMENT❑ DISTANCE TO NEAREST., Septic Tank __ Sewer Lines _ Pit Privy -- Sewage Disposal Field_ Cesspool/Seepage Pit Oth9r- Property Lino Frtvate Domestic Well--_- Public Domestic Well - INTENDED US8 ❑ CABPLEQOOLLL Dia.of Well Excavation C INDUSTPIAL � ❑¢OMESTIC/PRIVATE • 13 'DRILLED Dia.of Well Casing ( ODOMF.STie'/PUBLIC ❑ DRIVEN Gauge of Casing _ G C3 IRRIGATION ® GRAVEL PACK Depth of Grout Seat • ❑ CATHODIC PROTECTION ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER -• Other Information — ❑ GEOPHYSICAL Surface Seat Installed By:--. PUMP INSTALLATION: Contractor_ Type of Pump -- H.P. PUMP REPLACEMENT: n State Work Dore. S PUMP REPAIR: 0 State Work Done - -G DESTRUCTION OF WELL' Well Diameter__ - / ~ Approx ete Depth ��—- Describe Mat rial and Procedure 1 hereby certify that I have prepared this appiicati and that the work will t»done t ecordanee with Sa oaquin in e' r ordinances,state laws,and piles and regulations of the San Joaquin Loedl Health District Home owner or licensed ager rs signature certifies the following:"1 certify that In the performance of the work forwhich this permit Is issued, I shall not employ any person In such manner as to become subject to workman's compensation laws of California.' Contradoes hiring or subtcnuacting signature certifies the followin¢"I certify that in the performance of the work forwhich this permit Is issued.t shall empty p7lns subject t workmar,'s:ompensation laws of California.—`tion to grow and a final _ 4�<A3 Signed X . ,(,/_,,�_ g,: - - TltJr /CQ �< Datr (Draw Plot Plan on Reverse Side) FOR PEPAR HT USE ONLY q PHASE I iiyc-, c �ar� Date 4&-2? Accepted By-. � _7-- Additional Comments:-_- - Phavt 11 Grout Inspection Phase ll Final _ Inspection By Date Irspedicn By Date Fee Is Due:❑ ANNUALLY ❑PER UNIT ❑ PER SITE E3 EACH 13 jw wY+a Rrcq imd BY Jo.."31 O July t a Recereea� 311Jay a WE EXPLANATION BILLING � REMITTANCE S AMOUNT CUE CHECKED - DATE DATE REMITTED AMOUNT FEE 3,� — 1 pgORATION -------�-— �pENALTY _ O T HERPocemed toy _Q 2" fTOCKTOK CA 9=1AMMAurr-RETURM ALL COPKS TQ On""M xTAL WALT"K1tl11TfiO1rK[f ism L HAMILTON AYE.P.O.9"