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- Q <br /> A <br /> x <br /> k <br /> A pple a tons Will Be Precrssed When Submitted Properly Completed. Be Sure'.o Sign The AppIcal Ion. - <br /> FO_ROFFICE use APPLICATION k <br /> (For Non-Transferable,Revocable,Swpendabla) <br /> PUMP&V/ELL ! ., <br /> ENVIRONMENTAL HEALTH PERMIT V, sr <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY `� ' <br /> Application is hereby made to the San Joaqui n Local Health D;s!rict fora permit to construct and/or install 11ro wcrk herein described.This applications <br /> made in compliance withian Joaquin County Ordm.rtcc No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address .�j.-G'�s.-ti.Q-_1 .�____-_ —_ Cityrto,vn <br /> Owner's Name r11L_ _ Phone _�_(.-__ S_J <br /> '^7]}-5 .- >' -- -- ,� 7jt�� 366 <br /> Address 1__I0._L: '_:� r � �y$�e.�. City 17J, S,..d1-�- =�— ---- <br /> Contractor's Name ___License# Business non+ ` e- <br /> Contractor's Address — — _ Emergency Phone _ __—___ __ Lty, <br /> Is Certificate of Workmen's Compensation Insurance on File With SJLHO? Yes No s p <br /> TYPE OF WORK (CHECK): NEVI WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONO - <br /> WELL CHLORINATION IJ WELL ABANDONMENT 0 OTHER ❑ PUMP INSTALLAT!uNXi PUMP REP .IR❑ <br /> REPLACEMENT❑ Y <br /> DIS rANCE TO NEAREST: Septic Tank J— Sewer Lines �� Pi!Privy <br /> Sewaqe Dispose Field_�,�rL_„ Ce•aspcoliSeepege Pit._.=,Other <br /> Prop_rtY Line--1�.'_Prrcata Domestic Well Domestic Well __ rq; <br /> i <br /> 14TENC£13 USE TYPE OF WELL p 4 <br /> rGc'f INDUSTRIAL C CABLE TOOL Die.of Well Excavation--l�___ _._ ep <br /> ,. <br /> p DOMESTIC/PRIV'47E DRILLED Dia.of Well Casing <br /> DOMESTIC/Pi ❑ DRIVEN Gauge of Casing <br /> L7 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I7 CATHODIC PRO7ECTICN ROTARY Type of Grout <br /> DISPOSAL 11 OTHER _ Other Information <br /> u_GE^PHYSICAL Su-face Seat Installed By: <br /> PUMP!NSTALLATION: Contractor el r_,LyJA ✓ <br /> Type of Pcmp ' .S H.P.,_,� (' <br /> PUMP REP_ACEMENT: � State Work Ayy� <br /> PUMP ftEPAli#: ❑ c Ile Warr Done —�3,- <br /> DESTRUCTION OF WELL: Wer Diameter —: _ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance rrth San Joaquin I unty <br /> prcinances,state laws,and titles and r'eg,latlon5 of tiro San Joaquin Local Health Dis!rict. ^ <br /> 1;ome awner or licensed agent's signature n-ertffiss the following:"I certify that in the oetformance of the wo ro,wru Bh1hispe•mit " I <br /> is is.ued. I shall not emp:-1y any person in such maonpr as to necome sub)e-1 to workman's COTPe]^d!on iay.,of Carfe-oia:' t <br /> Contractor E hirinti orsuh-contracting signatureeeAl F,es the following:"I cerb', `..of in the performance of the work lorwhich this { <br /> pern%it is issued,1 shell employ persons subject to workmen's compensation laws of Cal forme �i <br /> t <br /> I Milla;1 fore,routV7,percilpr,prior to grouting and a final inspection. <br /> Signer' X _._yi!/E',av Title: <br /> . .Q1✓4,.C.�` Date: ---L� <br /> (Draw Flat Pian on Reverse Side) ,2 <br /> FO DEPARTMENT USE ONLY - '• ' <br /> PHASEI ''////JJ <br /> Application Accepted By__f/Lz�D _—_ _ Date LCE1�' ' <br /> Additional Comments:._.._ <br /> Phxae 11 Grout!nspactlon � 7P,h�as-ger III Final Inspection <br /> mspectior. By. Date . — insPecl:on By..{yJ.1fJ Date <br /> Pee <br /> It Due ❑ ANNUAL`Y ❑ PER UNrT PER Si TF ❑EACH ❑ January 1 8 Ra,,i//rvac By January 91 ❑a,".d R .ua By Jury 91 <br /> �` aDATEu_TNCE MOATEPEM TTEO REMIT <br /> ASE '%PLANATION <br /> fcE AMOUNT OLE CHECKED <br /> AMOUNT 'I(� <br /> LESS <br /> PR. RATION <br /> b <br /> e P of rdu. r 1 Na ueuance Dnte McI!p0 D611vFetl <br /> L APPLICANT RL"URNALLCGPR]Te: ENVIRONMEW.iLN trll yIr HAZELTON AVF.,P.O.1,r 10(i eTOOKTON CA 05101 <br /> tM <br />