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r Applications Will Be Processed When Submitted Properly Completed. Be SureTosign IneAppllcauon. t <br /> FfaR o,FeF E use: �In �� APPLICATION <br /> (For Non-Transferable, Revocable, Suspends <br /> ble)lko*� P&WELL <br /> 4 <br /> PUM _ <br /> ENVIRONMENTAL HEALTH PERMIT v/-� (2 05 T, . <br /> `1 '(_5 S �FE . WATER QUALITY �fl 2f ��F� -L5- <br /> (COMPLETE *. <br /> IN TRIPLICATE)�PG[/ <br /> Application isherebymadetothe a qui n Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in comp) c with-San J ounty Ordinance No. 1�2 and the rules and regulations of the San oaquin Local Health District. I <br /> Exact Site Address '" — _ F" `1 T City/Town <br /> Owner's Nam <br /> MY. ,/ o { 1tI /tl/ Phoney <br /> Address 7 <br /> se 2 <br /> City G i <br /> ! r # 3 `�I 3 Business Phone <br /> Contractor's Name <br /> Contractor's Address 2Qdten /A.1 4PS l Cam/ Emergency Phone { �_ � � <br /> is Certificate of 1Norkman's-Compensation I1n�surance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ 1� <br /> REPLACEMENT❑ /f�J <br /> DISTANCE TO NEAREST: Septic Tank,v �e� 99 Sewer Lines !� Pit Privy — <br /> Sewage Disposal Field /V0/�� Cessp��ro�9ol/Seepage Pit �`� ��' Other <br /> Property Line Private Domestic Well 6V��� Public Domestic Well <br /> INTENDED USE TYPE OF WELL /� <br /> 11 INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ,124QOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 2— <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL _ ❑ OTHER Other Information I <br /> El GEOPHYSICAL Surface fSeal Installed By: <br /> PUMP INSTALLATION: Contractor ,-- <br /> TYPe of Pump�2 rm w f^ s H.P. 4.0 <br /> /P <br /> .PUMP REPLACEMENT: ❑ State Work Done <br /> r' PUMP REPAIR: ❑ State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure IL. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 3 <br /> ordinances, state laws, and rules and regulations of the San Jo3quin,Local Health District. <br /> S Home owner or licensed agent's signature certifies the following:;I certify that in the performance 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." <br /> Contractor's hiring or sub-contracting signature certifies the following;"I certify that in the performance of the work for which this <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ill call)for a GrqA Inspection prior to grouting and a final inspection. <br /> " A� . [� rk-t Title: r[ ,D �l.r� R-t_ Date: ��~ ?-79 <br /> Signed X (Draw Plot Plan on Reverse Side) t <br /> a; <br /> FOR DEPARTMENT USE ONLY Q��* <br /> I PHASE I -_Q Date l o__14T0 <br /> t Application Accepted By Qh" d. <br /> Additional Comments: <br /> P e Grout spection` P as Itl Fina spection Ia / �, <br /> Date l lnspectio-By Date /v b 0 <br /> Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January•1_'&Received.'97-January at ❑ July 1 &Received By July 31 <br /> REMIT <br /> 1E "�` "F"' ' 'BASE EXPLAN'A7fON BILLING _ - REMITTANCE- _ AMOUNT DUE • -CHECKED- <br /> 1 DATE REMITTED AMOUNT <br /> h# FEE <br /> 1 LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> OTHER <br /> !6 o <br /> Received by - Date � Receipt No. Permit No. Issuance Date Mai4ed Delivered <br /> k APPLICANT—AETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE-P.O.Box 2009 STOCKTON,CA 95 <br />