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_�-. l- x5x«:71 ?•ar N,^�, .11 11 <br /> a K �7"° fr ".;ric ,i a{' - -r v' s. "+ � c�-o'a'4r&�14 <br /> 1 '� A-gyp c'"�`: J « '�if3b '>�.ay 3'g ., e�C ,r.. ✓ <br /> i 1 �+' '' ! -j f,Ri <br /> r d-ye ?,, H r. a� F57""y .Y.' fr,-iAV <br /> a.' . <br /> ,E S'r t 'M1=: h .. ej�;F�"-.,?..f..a�R..f <br /> ^' WATER Q1lAL1TY Iication is <br /> :COMPLETE IN TRIPLICATE) (J <br /> and the/�ul s nd r�Iao e San Joa uin Local Healtfi District. <br /> ation is hereby madetotheSan Joaquin Locai Health Districtf ar a permitto construct andlor install the work herein described.Thls app_4ppllc [ Cmade in compliance with San Joaquin County Ordinance Ne. 10862 /Town <br /> xact Site Address Z HI <br /> I A Phone S� <br /> $ E <br /> Fvvner's Name ^xcity <br /> CmiL� <br /> Address # `, R w License#AIL <br /> Business Phone <br /> il <br /> Contractor's Name X0Phone r4X3 �w��r. EP. Emergencyontractor's Address e�• No <br /> Is Certificate of Workman's Compensation Insuranc Fiie❑With SJRL CONDITION❑ DESTRUCTION❑ <br /> YPE OF WORK (CHECK): NEW WELL DEEPEN <br /> rNELL CHLORINATION <br /> ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR© <br /> } l r-^ <br /> -,3EPLACEMENT❑ Pit Privy <br /> I �a �- Sewer Lines r-+ Other <br /> DISTANCE TO NEAREST: Septic Tank �� Cesspool/Seepage Pit <br /> Sewage Disposal Field rte'' <br /> ,. Property Line Private Domestic Well �•�" Public Domestic Well r <br /> INTENDED USE <br /> TYPE OF WELL Q�t <br /> ❑ GABLE TOOL Dia. of Well Excavation G <br /> l IND AL " Dia of Well Casing <br /> Y <br /> 13 DRILLED Z <br /> OME57lC/PRIVATE„ 13 DRIVEN Gauge of Casing <br /> j J DOMESTIC/PUBLIC Depth of Grout Seal / <br /> El IRRIGATION 11 GR ACK f Al�hf I T <br /> OTARY , Type .of Grout <br /> Fk CATHODIC PROTECTION Other Information <br /> :DISPOSAL ❑ OTHER <br /> i Surface Seal Installed By: � <br /> ❑.GEOPHYSICAL <br /> cUMP INSTALLATION:. Contractor <br /> Type of Pump H.P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> f UMP REPAIR: ❑ State Work Done <br /> )ESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth a <br /> LL jl Describe Material and Procedure <br /> I hereby certify that I have 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 Health District. <br /> Homeowner 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 forwhich this <br /> pe Ift <br /> is issued, I s all employ pe ons subject to workman's compensation laws of California." <br /> I wt#all for a Gro pect' ri r to g Liking and a final insp lion. <br /> Signed X Hate: FC <br /> .1 (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE 1 / <br /> Date Q C� <br /> Application Accepted By <br /> Additional Comments: <br /> i <br /> Phase Il Grout Inspection P- t i I Inspection�/� <br /> Inspection 8y t Date �Z Inspection By Date <br /> Fee Is Due: ❑ ANN ALLY 0 PER UNIT PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &ReceivedREMIT <br /> uIy 3ti <br /> - BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE J <br /> LESS <br /> PRORATSON <br /> PLUS <br /> PENALTY <br /> If OTHER <br /> l OTHER <br /> i <br /> > <br /> Received by Rer`�"''7'ie, Permit No. Issuance Dale Mailed Oehvered <br /> l Uat� - <br /> *- <br /> -L_ APPLICANT—RETURN ALL r ..HEALTH PERMITISEPwICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />