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P <br /> ff y!'Ij <br /> jl STI .- 'L'-Y'L'-YP1 f <br /> ' A ttI1 Wile Processed W1trLmltled Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE usE APPLICATION <br /> 019_ j{�g 3 � r Non-Transluable,Revocable,Suspendablo} <br /> tMV_ � �t►'� PUMP&WELL <br /> '(COMPLETE IN TRIPLICATE SAN aogQIJ11V TR CT O�MWATERL QUALITY PERMIT' 6'� � <br /> ATE)SAN ojs a �7 � <br /> Application is hereby made to thesbfrTri 1q" # <br /> quln Local Health District for a permit to construct and/or install the work herein described.This application is n <br /> ,made In compliance w! JoaqCOUQW Ordinance No. 1862 anath rules and regulations 01 the San oaquln LocaLLIonlt District. , <br /> Exacl Site Address City/TownT <br /> Owner's Name ,`- <br /> - -- Phone Y 1 <br /> rrlddress —if C.1to-v — <br /> Jontractor's Name City _. r-- , <br /> ' �f' �P�^� License a Business Phone <br /> � <br /> �ontreclor's Address^ �— ��'�� T7"� Emergency Phone wy <br /> i Is Certificale of Workman's Compensation Insurance on File With SJLHD? Yes No _—� z,i, <br /> YPEt?F WORK(CHECK!: NEW WELL DEEPEN❑ RECONDITION 13 DESTRUCTION❑ q`1 ' <br /> �i YELL CHLORINATION❑ WELL ABANDONMENT❑ L OTHER ❑ PUMP INSTALLATION�� PUMP REPAIR C� ' <br /> "AEP, ACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank —_ Sewer Lines Pit Priv l <br /> r Sewage Disposal Field— Cesspool/Seepage Pit Other_ s <br /> Property Line Private Domestic Well_T,_.._,. Public Domestic Well <br /> i - INTENDED USE TYPE OF WELL _ ; y <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> OOMESTIC/PRIVATE 0 DRILLED Dia,of Well Casing v? <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> J IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal— <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout _ <br /> J DISPOSAL OTHER _ Other information <br /> GEOPHYSICAL ur a Seal Installed By; <br /> ",UMP INSTALLATION: Contractor_ v'►�"�'^� t 4•. J <br /> Type of Pump Igoe H.f. La�� <br /> MP REPLACEMENT: 0 State Work Done " "? <br /> UMP REPAIR: 0 <br /> State Work Done <br /> `wESTRUCTION OF WELL: Well Diameter _ —_ Approximate Depth <br /> Describe Material and Procedure �s <br /> I hereby certify that I have prepared this application and that the work.will be done in accordance with San Joaquin County ra <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies tho 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." 0 <br /> Contractor's hiring or sub-contracting signature certifies the following:" erldy that in the perlormanca of the work for which this (n I <br /> per !d,I shall emrr p sons subject to workman's comp tion laws of California." A <br /> 1 ill c t ihs�on p.or to grouts g and a final I n. <br /> yF <br /> fined 7i — -- — _-- Title -- Dater <br /> (Draw Plot Plan Reverse Side) } <br /> oF <br /> F R DEPA TME NT USE ONLY ` <br /> PHASE 1 lE <br /> Application.Accepted By _ --_�y Dale ��' dst <br /> F • Addrr anal Comments: __ <br /> Phase 11 Grout Inspection ha li al Insbectlons <br /> Inspection By _ DateInspaction 11 &1 <br /> i <br /> Fee Is Due:D ANN_UA.LY ❑ PER UNIT 10 PER SIM ❑EACH ❑ January I d Re erveC By;anwry 31 0 Jule 1 a necelred Sy July 71 <br /> � -� ..---- <br /> 1 EXPLANATION I 01LLING 1 REMITTANCE. f AMOUNr DUE CHECXEd r <br /> I 1 DATE } REMIT <br /> DATE REMITTED <br /> PEE `- ... ----- - - <br /> LESS <br /> PRORATION l I [ <br /> PLUS <br /> h PENALTY <br /> �s <br /> OTHER <br /> OTHER - <br /> R <br /> F Re[ewe0 by Day' Ne[c.01 No P.rmd Nv -_---- — - -1 uua+>Ce Dale MAded-----Deh.ered <br /> �„_ AP►LICANT—RETURN ALL COWES TO. ENVIAON"INTAL HEALTH Pt�Sn'-ERVICES 1!07 E.HAZELTON AVL,.P.O.Be.2009 STOCXTON,CA 95201 J. <br />