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r APPlicatfOns Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ,. <br /> .. "+AF f USE:"' 1 APPLICATION <br /> 1 <br /> '..3 (For Noh-Transferable, Revocable, Suspengable) <br /> ! k ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> I,SOMPLETE IN TRIPLICATE) WATER QUALITY <br /> Plication is hereby made to the San Joaquin Local Health District fora Permit to construct and/or install firework herein described.This application is <br /> made in compliance with San Joaqui Coun Ordii Ce No. 186 a d the rule�and regulations of the San JOS o al Health District. <br /> Exact Site Address L /Af �b j d�/�/ � City/Town_ <br /> Owner's Name cllao AVAL12t i rim Phone w <br /> Address <br /> ,City 7��-�- <br /> r Contractor's Name License# /fr'-+J. 'J 4 Business Phone 'Y— O F'v ' <br /> ? Contractor's Address !d Emergency Phone r <br /> I Is Certificate of Workman's Compensation Insurance on Fit ith SJLHD7 Yes X, _ O <br /> TYPE OF WORK{CHECK): NEW WELL❑ DEEP ❑ �" No <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ RECONDITION❑ DESTRUCTION❑ <br /> j REPLACEMENT❑ OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR IN <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 4--CeSspoOI/Seepage Pit . - Other <br /> Property Li Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED 1Dia.of Well Casing j <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 13IRRIGATION Gauge of Casing <br /> _ ❑ GRAVEL PACK Depth of Grot{t Seal e <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 7fD OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> I 1 <br /> PUMP INSTALLATION: , <br /> Contractor <br /> Type of Pump— k^y L p ®• -� Q' <br /> H.P_, 9/' <br /> PUMP REPLACEMENT: F]-State Work Done <br /> PUMP REPAIR: '`- <br /> State Work Done �+.� o M to ixsea. e+�� I TRUCTION OF WELL: W611 Diameter r <br /> Approximate Depth SI <br /> Describe Materiel and Procedure b <br /> hereby certify that I nave 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 HealthDistrict. <br /> Home owner or licensed agent's signature certifies the following:"I certify that In the performance of thejNOrk forwhich 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." j <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wii call for a Grout Inspecti In ri to r In and a al inspection. <br /> Signed X - <br /> " idPw I e: P + ) <br /> Date• l let) <br /> (Draw Plot an on Reverse Side) <br /> F RD PARTME I^t USE ONLY - <br /> PHASE ] , <br /> Application Accepted By ° Date S/ �d <br /> Additional Comments: ! <br /> Phase 11 Grout Inspection <br /> ha 1 al lnspsction q <br /> Inspection By Date - Inspection E Date iv 4910 <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT' O PER SITE .❑EAgtt <br /> ❑ January 1 a Received By January 31 ❑ July t a Received By July 31 <br /> BASE EXPLANATION BILLING 'REMITTANCE E REMIT <br /> GATE DATE REMITTED (AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE '/ <br /> LESS <br /> PRORATION ` �., �('Ir <br /> PLUS <br /> •. +PENALTY <br /> OTHER - <br /> OTHER ` I <br /> �R To <br /> .��Raeoivad by '..: �peie;' ' ,Receipt No. .,.�"" Permit No. In ce Dete Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENiAI.HEALTH VERMIT/SERVICES' t 1 E.NAZELTON. �l Ii S <br /> �:jiy=x w� �.. '�+}rf.: •:,^ 69 AVE. P.'O:9o:1009 6TdCXTON,cA 9= <br />