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r Applications tN""It Processed When Attu Itted Properly Completed.f �;;ire To n.Si The n <br /> ••-' I'OI! OYFICE Usk: „ PPf.ICATION ° Application, <br /> nr <br /> F I ( rpr�Non-T�emlerable,Revocable.Suspendable� # N <br /> l PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (CpreNiese IN TRIPLiCATI:) WATER QUAUTT } <br /> t�lrl;�u-Irr-tri r.Juyrnbyrnndutothe <br /> Sed- <br /> R c utP c�IHoang1strictf4ra rm to construct and/or install thew4rk i described.ThsSpoilcationt& ' <br /> n fldE, : c rrnpnnnce wrtt►S Jo yf Coun r inance N 862' 5�a regulations 4f th@ 5a � - <br /> I:+url S lu Address ���' f�7 �,i', <br /> �3 f/�(,q — 'City/Town ' <br /> - Alldr[s;:9 ."-T Phone <br /> h City <br /> Canlr4clor's NArna _ _ <br /> On"N Buses Phone <br /> 0 6�A►' <br /> CuaHaclgr'6 Address Emergency Phone .. :n <br /> s_ Is CaruhCale of Workman's Compensatipn Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK(CHECK):. NEW WELL❑ DEEPEN❑ 'i RECONDITION© DESTRUCTIONC�: `. <br /> WELT. CHLORINATION© WELL ABANDONMENT❑ <br /> k. OTHER D PUMP INSTALLATION PUMP REPAIR© fi ' <br /> REPLACEMENT( ( <br /> + r DISTANCE TO NEAREST: Septic Tank Sewsr Lines " <br /> ` Pit P y <br /> it r y Sewage Disposal Field Casa Other '' ; ' .s <br /> tx :: Po4USeepags Pit <br /> Property Line Private Domestic Well Public 4omestic IAieli <br /> ' INTENDED USE TYPE OF WELL p <br /> ❑ INDUSTRIAL <br /> 0 CABLE TOOL �� Dia.Of Well Excavation- <br /> ,rA G DOMESTIC/PRIVATE ❑ DRILLED '` u <br /> 1 DOMESTIC/PUBLIC ❑ T Dia.41 Well Casing <br /> DRIVEN taupe of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> Depth at Grout Seal c t t <br /> } ❑ CATHODIC PROTECTION ❑ ROTARY .� 'ty <br /> ' ❑ DISPOSAL Type of Grout <br /> 13 0 OTHER_ Other Information <br /> GEOPHYSICAL Surface Seal Installed By: " <br /> i PUMP INSTALLATION Contractor <br /> t i Type of Pump R <br /> PUMP REPLACEMENT: lYState Work Do M.P.P <br /> ' PUMP REPAIR: D State Work Do l <br /> DESTRUCTION OF WELL: Well Diameter if <br /> Describe Material and Procedure31 <br /> Approximate Depth ' s �t# <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San J <br /> a' ordinances,state laws,and rules and �q oaquin County, <br /> regulations of the San Joaquin Local Health District ? t <br /> Home owner or licensed egimrs ftnNurg ONU es the follotelrp:~l certify that in the performance of the work for which this <br /> .is issued, I shall n lay any person In such manner as to become subject to workman's cpm permit <br /> peneatian laws California." <br /> ' Contract reyb.cpn z" <br /> eerflllae cite fpllpwlttg:"I c that in the Performance of the wort!for which this <br /> Permi s i u lie Ply ubJeci to workman's compen n laws of California <br /> 1 will call x . <br /> 1 Signed X Tittr iC !r` <br /> ` <br /> Ditto: <br /> (Draw Plot Piano verse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Y fi k <br /> ' <br /> Application Accepted By ,�` 51 <br /> Addilional Comments: , <br /> 1 s <br /> - Phase 11 Grout Inspection � <br /> ( Inspection By_ Date 11{ <br /> Insvection B ate ry <br /> F@@ Is Due. <br /> ❑ ANNUALLY ❑ PER UNIT C3 PER 517E ❑EACH <br /> it ❑ Jaenus a Received v " Rl. <br /> - wry.31 ❑July,a Recawa By.lufy 31 <br /> 1'a BASE <br /> EXPLANATION BILLING REMITTANCE s '' RElYaT ,_4*, <br /> _ DATE DATE _ REMITTED AWU(NT�tWE QIECKW <br /> :AMOUNT <br /> LESS `^� ? v } 6 <br /> PRORATION <br /> PLUS _ ' �'r �t4 <br /> PENALTv <br /> r� <br /> ot"t it <br /> '#� „ .,-cr/ Ikra,. --, '_ .-•pace pl No•�_^^'-�-���._�--..�._�(](1 .��.. .. - _ �,3.- 1 <br /> Permit No. --- Isiwrlca 00aa�j' "IW <br /> ..:AW—HETUA04 AL_ COPIES Tq; ENVIRONMENTAL"MTN P9ftA1JT/sERYICEa <br /> 1 W s L.ilA=eLYpN AVE..P.O.eo,7e04 sTOCKTpN,CA gms. <br /> y e t <br /> gra <br />