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FOR OFFICE USE: APPLICATION y' ax-.�.• <br /> (For Non-Transferable, Revocable,Suspe °`.,/ `PU44 <br /> WELL <br /> ENVIRONMENTAL HEALTH PE Nov 10J 1980 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/oE;r ll In h6ei Ai 'bed Th is application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations p sL r �',' Health District. <br /> ic <br /> Exact Site Address I7-410 B. LnGYey- Rm. City/Town CT <br /> Owner's Name L), 5_6g5p _MIJC_ Phone <br /> Address��0• D Rp>L2 N 2 City Ley,YABS::tRC <br /> Contractor's Name C pC�}R1Nt� T>L)MP License k-:SC)968 I Business Phone-127—Fri qR o <br /> Contractor's Address I"�p.130V 1(31 - fXILEi-bR0 Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION El DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR —9 <br /> REPLACEMENT❑ 2 pLA.m ps. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC .❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL -:❑ OTHER` Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ype of Pump H.P. <br /> PUMP REPLACEMENT: 3 State Work Done FWTI&I— 156")rkiny--nelAt2+a1t^5/JS i-ND .Q1i(Itf1SIm <br /> PUMP REPAIR: ` ❑ State Work Done�lyhp=t2-3ohR�taybf�'N— Y1¢I,U t1171u.2IS'F ?.0 A}'. PAtjgjpq� <br /> DESTRUCTION OF WELL: Well 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 with San Joaquin County Q <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 theperformance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." �1 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit 1 ss , I shall employ persons subject to workman's compensation laws of California." <br /> I w i G t Inspection prior to grouting and a final inspect n. �A <br /> Signed X Title: Date: <br /> (Draw Plot Plan on R verse e) <br /> i <br /> FOR DEPARTMENT USE ONLYJ.�a, n„�� <br /> PHASE I t VI- <br /> Application <br /> IApplication Accepted By Date, <br /> Additional Comments: <br /> Phase I�I Grout Inspection Ph e I trial Ins tion <br /> Inspection By�..a_I.q Date Inspection By at z v�� <br /> Fee IS Due: ❑ ANNUALLY 1❑�'P'ERR-U-�NIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> C AMOUNT <br /> FEE ,� / <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Isauance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTON AVE.,P.O.Boa 2008 STOCKTON,CA 95201 <br />