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f <br /> Applleations will Be Processed When Submitted Properly Completed.Be Sun To Sign The Appllcafbn. <br /> FOII OFrfICE USE: APPLICATION <br /> - — (For Non-Transferable,Revocable,Suspendable) PUMP At WELL <br /> - - - ENVIRONMENTAL HEALTH PERMIT <br /> _ (COM/a -IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or Install the work herein described.This application is <br /> M11111111111 in compliance with San Joaquin CLsounty rdinance No. 1862 and the rules and regulations of the San ulr Local Health District. <br /> Eaglet Site Address (-/O _�/' 4 City/Town --- <br /> zi- - <br /> Ow ws Name —- _--—_ Phone w — <br /> AI/drossCit <br /> 2r y <br /> contractors Name License eL(.13j? BI, + Phone_3 1 <br /> U. <br /> Contractors Address /40 !09 � Emergency Phone 65 4 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD9 yes No ---- <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑ OESTRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Linty _ Pit Privy <br /> Sewage Disposal Field _ CatapooVSNpage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDI'9TRIAL ❑ CABLE TOOL Dia.of Well Excove"n 1. <br /> JL DOMESTICMAIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRtGATION ❑ GRAVEL PACK Depth Of Grout SNI <br /> ❑ CATHODIC PROTECTION O ROTARY Type of Grout <br /> ❑ DtSPi'NSAL ❑ OTHFR _ Other Informatioh <br /> ❑ GEOPHYSICAL rises Seal Installed By: <br /> P1AN INSTALLATIO/f: Contractor <br /> Type of Pump H.P.-.—.L <br /> PUMP 11!'LJICEMINT: ISlete Work Done JeA <br /> FIM IM►AII! ❑ State Work Done <br /> O1lSTRUCl10N OF WELL Well Diameter ______ Approximate Depth <br /> Desorib-Material and Procedure - <br /> I hereby certify that 1 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 /> "o"Hi etsrtar or lits v d agonft slgnahMe osrtifte ft following:"I certify that,n the performance of the work for which this permit <br /> Is issued, I shall not employ any poison In such manner as to become sub(ect to workman's compensation laws of California." 777TTT <br /> CoMr~s hill"or wb-eorovele q signature oerNlles tea lollowing:1 certify that in the performance of the work for which this �t <br /> parmFt to issued. I shall employ persons subject to workman's compensation laws of California." <br /> 1 srN t o O►ou1 th ton prior lo g ng and a HnM <br /> 11114nod X }.Lilpe: — Date — �� <br /> (Grew Plot Plan on Reverse SI ) <br /> FOR DEPARTMENT USE ONLY J <br /> PIAS!I / n <br /> Appuo.ewr �l Aoospeld By� 1�-1.Lf -— ate '� 3 <br /> Additional Comments: — <br /> Pima It Orout I wpeotloft of Final Inspection <br /> inapaellon By — Dale Inspection By rL _ Date ��' -- <br /> tis to Dsls•.O AMrimAy O O rE"e1TE O EACH O Jseuery 1 a"sashes Sy Jon wry 71 ❑July 1 +n•cerw By Jew 31 <br /> aAti! EIt/LANATION aILLINO "EMITTANCE E AMOUNT DUE CHECKED <br /> DATE DATE "EMITTED AMOUNT <br /> .EE S �R —- <br /> i"DnATrosr --- <br /> r <br /> OTHOR <br /> OTHER —----- <br /> nl.cn.w a -p�----- -- 1lseapr rye rer,na No Mule oelwaiA <br /> Awucm,_01TUMr Au cope To, aNworelnnAL"FAUN PMMTisa111rlese neer a.HAtKTON Ay!"W0.lift suss aTOpiTOM CA sass" <br />