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+ Applications Will Be Processed When Submitted Properly Compietea.be aure Ioa1911 .„vnrr••�-•• <br /> FOR OFFICE USE. APPLICATION <br /> (For Non-Transferable, Revocable, Su �e� r+ <br /> } � � 4W.ItAP&WALL <br /> ENVIRONMENTAL HEALTH <br /> t WATER QUALITY AP� �� 00 <br /> {COMPLETE IN TRIPLICATE) "' <br /> Appl ication is hereby made to the an Joaquin Local Health Dist l tforapermittoconstructand/orinstal t Or inmeibed.ealth District. is <br /> made' c I' with.San oaquin County Ordinance No. 1862 and the rules and regus"s e an Joaquin Local Health Districk. <br /> Q � <br /> Exact`�,e,%d L `bo o syr Phone DISTRIcr <br /> f <br /> r'f s <br /> Owner's Name Marti n <br /> Address <br /> bPY, - city Cy <br /> Contractor's Name C��h�11g pt�mn License# 309031 Business Phone 727-55 j { <br /> Contractor's Address _g.0 •Box 113 Lockeford Emergency Phone 727-5548 <br /> Is Certificate Of Workman's Compensation insurance on File With SJLHD? Yes No <br /> �_.— <br /> TYPE.OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION El DESTRUCTION[] <br /> PUMP INSTALLATION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT El OTHER ❑ PUMP REPAIR El II <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/seepage Pit Other j <br /> Property Line Private DomesticrWell Public Domestic Well <br /> INTENDED USE <br /> TYPE OF WELL <br /> ~ , <br /> ElCABLE TOOL '.Dia. of Well Excavation <br /> ❑ INDUSTRIAL <br /> Well Casing <br /> ❑ DOMESTIC/PRIVATE 13 DRILLED <br /> D+3.bf a <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVENGauge of Casing'• <br /> ❑ IRRIGATION <br /> ❑ GRAVEL PACK { Depth of Grout Seal— <br /> ❑ ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION ,' � <br /> 11 DISPOSAL ElOTHER Other Information <br /> i <br /> 1:1 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor GOerl' 111 Pum & I 1 t on I C • ' <br /> Type�f Pu pSer p { H.P. 7- r <br /> 13 State Work Done <br /> PUMP REPLACEMENT: <br /> I PUMP REPAIR: ❑ State Work Done - <br /> t s~Approziir.dte Depth <br /> DESTRUCTION OF WELL: Well Diameter w <br /> Describe Material and Procedure <br /> 1 have prepared this application and that the work will be done y <br /> ,in-accordance with San Joaquin Count <br /> re <br /> I hereby certify that p P <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:"l certify that in the perfdrmance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workmant.;compensation laws of California." <br /> Contractor's h rsub-contracting signature certifies the following:"I certify that in the perforrnand of the work torwhich this <br /> r permit'is' a shad employdpersons subject to workman's compensation laws ofCalifornia."x <br /> 1 I <br /> I will rou hspecti n prror to groiiting and a final-inspection.- { <br /> Signed X <br /> Title: BooKkeppe Date: 04/24/80 <br /> (Draw Plat Plan on Reverse Side) <br /> I FOR EPART NT USE ONLY t <br /> PHASE l t Date <br /> 4 Application Accepted By <br /> k <br /> Additional Comments: } <br /> P Fina <br /> Phase II Grou Inspection i l pection f •+�, <br /> Inspection By <br /> ate Inspection-By, ate <br /> Fee Is Due: C3 ANNUALLY C1 PER UNIT ElPER SITE•rw•.t, D;EA : .,_❑Y January 1'&'Received By January 31 July 1 R Received By July 31 <br /> _ REMIT <br /> ~BILLING REMITTANCE $ AMOUNT OLE CHECKED <br /> 1 BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> yS� FEE - <br /> LESS <br /> III PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 01. <br /> OTHER <br /> c5 55� 4 2� <br /> Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> Received by <br /> -APPLICANT—RETURN ALL COPIES TO! ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.D.Bax 2009 STOCKTON,CA 9520 <br />