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++ �a�Ls F T <br /> Applicalionss Will Jo erocoacad When Submitted Property Compteled Be Sure To Sign The AppilaLilon <br /> —FOR OFFfC£USE APPLICA' ICN <br /> (For Non-Transferable Revocable,Suspondable) PUMP&WEi.L <br /> ENVIRONMENTAL HEALTH PERMIT � � ,,-t r'n@ LOCAL <br />' (C0MPL£TE IN TRIPLIGATE) 7NATE0 QUALITY <br /> DISTRICT <br /> AppIicalionisherebymade toI"SanJ�agul0LocaIHeaIthDlstncttorapermlttoconstruct and/or in alai Ithe work <br /> heramdescribed 7h+sappGCauonl4 <br /> made in compi3ancewith San Joaquin ounty Ordinance No 1862 and th rules and regulations of the San aquln Local Hesith District `� { <br /> l�fit/ _ p ��� <br /> Exac' Site Address L(d, r CC�� w — City/Town <br /> f ISO <br /> �rie <br />' Owners NaAddss <br /> _ y <br /> Y r <br /> 1 ContrCI actor s Name License p uslness Phone <br /> j Contractor s Address <br /> Emerguncy Phone <br /> is Certificdte of Workman s Compensation Insurance on Flle With SJLHD? Yes No i <br /> TYPE OF WORK(CHECK) NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION z <br /> WELL CHLORINATION ❑ WELL A13ANDONMENT 13 OTHER ❑ PUMP INSTALLATiON PUMP REP <br /> + REPLACEMENT D <br />' DISTANCE TO NEAREST Septic Tank Sewer Lines Pit Pavy - <br /> + Sewage Disposal Field Cesspool/Seepage Pit O'her� <br /> Property Line Private Domestic Well Public Domestic Weil <br /> INTENDED USE TYPE OF WELL t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia of Well Excavation <br /> j C DRILLED Ole of Well Casing <br /> ❑,� �D ESTIC'PRIVATE _ <br /> l!3'DOMESTiClPURLIC ❑ DRIVEN Gauge of Casing t <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -- —� <br /> I ❑ ROTARY - Type of Grout -� <br /> 3 ❑ CATHODIC PROTECTION <br /> DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ <br /> ❑ GEOPHYSICAL Surface Seat installed By _ }y <br /> r � <br /> { PUMP INSTALLATION Contractor - <br /> ? ,,T�yppee of Pump H P <br /> R PUMP REPLACEMENT 4Ei ork <br /> PUMP REPAIR Sork Dore G T <br /> Approxima'e Depth <br /> DEWell Diameter STRUCTION OF WELL r > <br />' Describe Material and Procedure J - <br /> t <br /> 3 ~ <br /> I liereby certify that [ have prepared this application and that the work will be done In accordance with San Joaquin County +,` <br /> r ordinances state laws and ruses and regulations of the San Joaquin Local Health Distnc' <br /> rtifies the following t certify that In the performance of the work farwhictt this oermlt <br /> Home owner or Ilcensed agent s signature ce <br /> ` Is Issued I shall not employ any person in such manner as to become subject to workman s compensation laws of California <br /> tf Contractaes hiring or Sub-contracting signature certifies the following I cdrtify that In the performance of the work It r wnich this it <br /> ploy persons subject to workman s compensation laws of CaMornia <br /> permit is Issued t shall Pm ' <br /> { I wi r a Grout Inspects rior t roulin nit a final Inspection y '21 A <br /> Title Dale a <br /> Signed <br /> IDravir Plot Plano 1 Reverse Side) <br /> AR <br /> FOR DEP AR USE ON Y <br /> PHA`` f ��IA ��/!�j IGvi r Pate q�1 <br /> Application Accepted y <br /> Additional Commenlsk <br /> Phase It Grout Inspection rWtnse Kl Ffnalanspection <br /> inspection B t r i'-!` Oa a <br /> Inspection ay ` Date p Y~'—� <br /> f <br /> Fee Is Due © ANNUALL\ C1 PER UNIT ❑ PER SITE ❑ EACH © anuary 15 ReceweG BY January 71 idly 1 8 HBte+rREMITBy uIy 31 L <br /> I -� BILLING I REMITTANCE s AMOUNT OUE CHECKED ^+ <br /> BASE I EXPLANATION DATE GATE REM,TTED AMOUNT <br /> i 4 s <br /> FEE I .=t~1 1 t f I .4�C <br /> i <br /> LESS � I <br /> PA ORAYI�N <br /> PLUS T _ <br /> PENAL`' <br /> 1 OTHER <br /> O-HER I I I I tr <br /> R.'e-od by Oav <br /> pece�wl No o.+mi7 No nuance sfe MaileE� pel+rersd <br /> i APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERM T+SERVICEB 1601E HAIELTON AVE AO acre 8000 S�C+CKT4N CA 93201 <br /> 4 <br /> 9 <br />