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i <br /> 'Ietld Be Sure To Sign The Appllcat <br /> Applications Will Be Processed When Submitted PLICATIONn.. <br /> FOR o f�E-USE: PUMP <br /> (For NontTransterrable,Revocable,Suapendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 'L �\ b)yd � WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> i, regulations rl the San Joagy n Lccal Health DBlnct. <br /> gpplicaU^.n is hereby made to the San JoaquinLocamanceNoS11862and the rules and�toconstruct erm.tand�ortnstalltheworkherernde�i� 7hisapPl� <br /> made in compliant?with San Joaquln Co Ordinance ._ f ` (,e' �Cily Town ��lf/�� C <br /> Exact Site Address �� ' - ---�� Phone <br /> Owner's Name /4'Q?C� (1'K� City7Xa <br /> Addresc ,,' Peo <br /> �� Lcensep �770/ BUSIne.SsPhr'Cuntraclors NaTe L `4 .� EmergFncy Phone <br /> Contractor's Ad+ essQ. °`fT " No <br /> Is Certificate of Workman s Compensation InsureF,R,Ith SJLHD) Ves <br /> TYPE OF WORK (CHECK): NEN WELL 0NDENT❑❑ OTHER RECO❑ ITI POP INSTALL TIION❑ PUMP REPAIR <br /> WELL CHLORINATION❑ WELL <br /> REPLACEMENT❑ Pit Privy <br /> ` Sewer Lines �t.2. Other ---- <br /> /V�_ <br /> DISTANCE TO NEAREST: Septic lank Cesspool SceDa9e Pit <br /> Sewage Disposal Field 4104co public Domestic Well__ --- <br /> Property Line Private Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE <br /> ABLE TOOL Oia �.t Well Excavation <br /> ❑INDUSTRIAL ❑ DRILLED Dia.of Well Casing <br /> R'DOMESTICPRIVATE Gauge of Casing -- <br /> ❑ DRIVEN <br /> ❑�.., DDOMESTIC'PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> a 2�IRRIGATION Type Of Grout <br /> ROTARY <br /> ❑ _-------___------ <br /> ❑ CATHODIC PROTECTION OTHER Other Information <br /> --- <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL c'r;�o f'("1 -- - - - - _.. <br /> Contractor H.P. - <br /> PUMP INSTALLATION: <br /> Type of Pump --- �— — --_ <br /> --- ---- <br /> PUMP REPLACEMENT: ❑ State Work Done-_--------- - <br /> PUMP REPAIR: <br /> [I State Work Done -------- Approximate Depth - <br /> DESTRUCTION OF WELL: Well Diameter------ -- <br /> Describe Material and Procedure-- -- -_—_ <br /> I hereb certify that I have prepared thI s application and that the work will be done in accordance with San Joaquin Cour <br /> Y <br /> ordinances,state laws,and rules and re. ulations o1 the Sen JOwl' oaquin Local Health Distriperform <br /> compensation Taws of Californ <br /> act to workman's comp. <br /> � Home owner orlicensed agent'sslgnmson!�ulch mannerlasto becomef subjtintheperformanceoltheworkforwhichthispen <br /> s issued. I shall nut employ any Pe g:,, <br /> r hiring or sub-contracting signs bject to workman's compensation laws of California <br /> lure certifies the following: 1 Certify that in the performance of the work for whit <br /> Contracto <br /> permit is lssr',% riI shell employ persons su " <br /> I will for a Grout Ins n or outing and a final Inspect on. c��../� <br /> ' grpate: <br /> �. -- Title: <br /> .- to -- <br /> Slgt;ad X Drew Plot Plan on Reverse Side) <br /> - FOR DEPARTMENT USE ONLY <br /> t1 <br /> Date _ <br /> PHASE I - -- - _-------- ----- <br /> Apnlication Accepted By-- 0 -- ---- <br /> Addltional Comment -_ _---- - asy1M Final lmpeeNon� <br /> Ph• r �t�I�n�sp�eate . �-=_A. p� Inspection By-s(�� A Date <br /> �(�.ti r�,...ate_�-t>�41-Jd <br /> Inspection O t Rec�rv.• <br /> ❑EACH ❑ January t a ReceKod By— <br /> Jan-Fee Is Due:❑ ANNUALLY ❑PER UNIT J PER SITE gEMITTANCE = AMOUNT DUE C <br /> --- ---- BILLING REMITTED A� <br /> BASE EXPLANATION DATE DATE - —- _ -- <br /> e <br /> - -'� - - - ---- y-3--- <br /> FEE - <br /> LESS --- -- - - -- <br /> PRORATION . <br /> PLUSPENALTY <br /> OTHER <br /> OTHER <br /> fed oeinered <br /> Pvrmo No Hau me 011lto <br /> + ---- Oel� ReCe+Pl NO t AI E.MAI[LTON AVE..I.O.aea 2000 STOC$(TOt <br /> ovAPPLICANT—AET <br /> LFA,-C-�d URN ALL COPIES TO: [NVIRONM[NTAL LM[ALTM►[11MIT/aMWC[a <br /> ik,s i <br />