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J! <br /> b ♦ - l <br /> r ' <br /> 11�� ;�rr�� LL11 '..t 1 gApplication. <br /> r U1WIIf>si Procisaed Wl�nbrtlllted Properly Compreted.Be Sure To Stn The <br /> �o OFFICE usE` (� C� APPLICATION <br /> JUN 3 0 1999,Non-Transferable,Revocable,Suspendable) <br /> ---- `� PUMP&WELL <br /> SAN 1�7AQUlN EMMONMENTAL HEALTH PERMIT <br /> "(COARPLETt's IN TRIPLICATE) uu��� piSTRiCT WATER QUALITY ; <br /> Application Is hereby made to the 6MTJ aquin Local Health District for a <br /> made In Compliance wi Permit to construct and/or install the work herein described.This application Is <br /> �;e4 Co Ordinance No. 1862 an th rules and regulations o!the Sen oaqui� ep ttyDistrict. l <br /> Exact Sile Address ff�� <br /> - -- -_ City/Town <br /> Owner's Name 4 77° <br /> rdresPhone _ _ ) <br /> �Onitacfollr,Nama ,. —' City—'r ���4License n BusinesPhone o"Cintractor's AddressTF' t <br /> Emergency.Phane <br /> Is Certilicale Of Workman's Compensation Insurance on File With SJLHD7 Yes` vNo <br /> ! <br /> PE OF WORK(CHECK): NEW WELL DEEPEN❑ RECONDITION DESTRUCTION 4� <br /> ELL CHLORINATION❑ WELL ABANDONMENT❑ . OTHER ❑ PUMP INSTALLATION CsY PUMP REPAIRQ <br /> IEF_gCEMENT❑ <br /> i <br /> DISTANCE TO NEAREST: Septic Tank <br /> P —__ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other. <br /> Property Une Private Domestic Well Public Domestic Well L <br /> '-INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> DIa,of Well Excavation '.p•; �' <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN <br /> '.J Gauge of Casing <br /> IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal— <br /> ❑ CATHODIC PROTECTION C ROTARYy <br /> J <br /> DISPOSAL ❑ OTHER TYPe o!Grout <br /> __ Other Information <br /> GEOPHYSICAL )�� ur a Seal Installed By., <br /> rUMP INSTALLATION: �' _ aL _.e (5Pc --•ys-�� ` <br /> Contractor / 1 <br /> Type of Pump <br /> UMP REPLACEMENT: -.. H.P- <br /> state <br /> Work Done <br /> MP roti ♦ iI '.:4;43j <br /> REPAIR: <br /> ❑ State Work Done <br /> wESTRUCTION OF WELL Well Diameter _� Approximate Depth f` <br /> Describe Material and Procedure_ <br /> I hereby certify that I have prepared this application and that the work will be done inaccordance with San Joaquin County <br /> ordinances,slate laws,and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies tho following;^t certify that in the performance of the work for which this permit '{ <br /> r- is issued. 1 shall not employ any person in such:manner as to become subject to workman's c;ompen;ation laws of California." +�2 <br /> I, µ Contracloes hiring or sub-conlracling signature certifies the following:" artily that in the performanc<+ut the work for which This <br /> r I R <br /> Por <br /> I shalt emip sons subtest to workman's Comp lion taws of California." <br /> 1 111 c 21- <br /> Ina�on p.or to grouts g and a isnot I n, <br /> gnarl)1 ! <br /> Title' Dale:� ..�. <br /> (Draw Plot Pian Reverse Side) ¢ <br /> } <br /> F R DEPA TMENT USE ONLY <br /> PHASE 1 // f <br /> Application Accepted By Date <br /> Additi4rial CommE:nts: <br /> Phase 11 Grout Inspection ha tl at Insbaction <br /> ! Inspection BY Date _- Imsp7Ction BY !%"Dale <br /> �. t r <br /> Fee Is Dire:❑ ANl4UA,Lr ❑PER uN1r 1p PEA 51 rE ❑ EACH ❑ Januar i <br /> Y i d ReewM fly January 3I ❑JdIY 1 6 Recerretl By July 31 <br /> I <br /> ASE I EXPLANATION I EALUNG REMITTANCE. S7AFAouN <br /> REMIT "� <br /> I i DATE OA7E REMITTED CHECKEp <br /> FEEPRORATIONaiusPEtI-r ------- <br /> C <br /> ! - -t ---- ---- -- - - -- ' <br /> OTHER � I - <br /> I E , <br /> -- --- — <br /> orriEp <br /> ----- _ <br /> M1 R![l..p OY Dar.r• H'Cl�pr Na Por T,r Nn ISSuaeca Dara MdllC -- pllwe,M -' <br /> [_,�. APPLICAMT-14EVURN alt COPlJ$TO. tNrIRONMENTAL NEALTM PNy.�•ERvtCES MI E.NAIELTON AVE..P.D.eo.2"- STOCMTON.CA IS701 , <br />