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t <br /> y <br /> i <br /> Applications Will Be Plot:Tased When Submitted Property Completed.Be Sure To Sign The Application. <br /> FO_R_OFFICE USE: APPLICATION <br /> (Foy Non-Tranclomble,Revocable,Suspendable) _9 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> J LL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY h <br />: . Application is hereby made to the San Joaquin Local He4rh District for a permit to construct an0'ol instalithework heroin described.Thisapplication isJ <br /> made in compliance with:.;an Joaquin County Drdhla ICO No 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address .._„iC1: rx.� G.�.r` — Cily/Town _— <br /> ti;; <br /> Owner' <br /> s Name c'�LIYL� _ _ —_ _ Phone <br /> ' �r _ <br /> Address .tLZ�n � =3! � Cny—_'LJ�4� 366 <br /> Contractor's Name __ __Licensea _ Business f+r.onE ____ Zf,; <br /> 5 Contractor's Address _ Emergency Phone <br /> Is Certificate of Workman*s Compensation Insurance on File With S.1LHD? Yes_ No - s <br /> TYPE OF WORK(CHECK): NEW WELL DEEPEN❑ RECONDITION❑ DESTRUCTION❑ -E <br /> WELL CHLORINATION•! ❑ WELL .ADA!!DONMENT ❑ OTHER ❑ PUMP INSTALLATIONX PUMP REPAIR I91 <br /> '.REPLACEMENTO <br /> DISTANCE.TO NEAREST: Septic—, —�.5--� Sewer Lines. O � <br />..:4� —_2..> Pit Privy <br /> Sewage Dispose!Fleid =_ COSSP401/Seepage Pit—_�-� Other— +� <br /> Property Une Private Domestic Wal!_>.fC_ Public Domestic Well <br /> INTENDED USE TIPS OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL Cia.of Well Excavation <br /> e rg DOMESTIC/PRV.'A"C l$OgILLED Dia.of.Vel!Casing <br /> L DOMESTIC/PUcuc ❑ DRIVEN Gauge of Casing_.r2_,,: <br /> i) IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 7 0 CATHODIC PRO"f E^,TION ROTARY Type of Grout 12A_ <br /> f <br /> • � � DISPOSAL 1 OTHER Other Information_ _ •�L <br /> GEOPHYSICAL Surface Seal Installed B PL ri' <br /> PUMP INSTALLATION: Contractor el t"✓ er <br /> Type of Pump..—_— stJ�._--_ H.P. <br /> PUMP REPLACEMENT: ❑ State\'fork Dona _ _ ___—'9 ', t <br /> PUMP RCPA.IR: ❑ Srate Werk Done <br />�.k <br /> DESTRUCTION OF WELL: Woll Diame.'er Approximate Depth <br /> Describe Mat vial and Procedure <br /> y' I en+:y cw IV that I have prepared this app I atlon and that the work will be done in accordance with San Joagc,n Caunty <br /> y'. ,.rdinances,state laws,and rules and regulations of IN,San Joaquin Local Health District. (� <br /> Home ownnrorficensvd_genes signature certifies the following:"I certify that in the porforrnanceof the work for which this permit \y <br /> .k is i3suee, I shall not enno;oy any person in such manner as to become subject to workman's compensation laws of California' w <br /> Co xtra.toYs hiring or sub-con!recling s!Bneture cer;!ties the following:"I certify that in the perlorrtiance o(the work forwhich this f i <br /> permit is issued, I shall employ persons,object to workman's rompensatiou laws of California." � I <br /> I wiltRall for a Grout I <br /> rpocilon prior to grouting and a final Inspection. / 'X <br /> 7 v <br /> Stoned X . z1.�.�_,�. -c._uv __. Title: 1.[hL✓_ __. Date:_42 <br /> i'/�$�_\ ! <br /> (Draw Plot Plan on Reverse Side) 7 <br /> t FO DEPARTMENT USE ONLY <br /> PHASEr <br />'t . ( Application Accepted DY — .—_ Dale <br /> Aoditional Comments: <br /> F <br /> Phase It Frout Inspection DPt ase III Final inspection <br /> Inspection Hy_ _—._ _. Date_. inspection By�"'�/ Date <br /> I <br /> Fee Is Due:❑ ANNUALLY C PER UN-' SI PER SITE 11 EACH ❑ January I ItReculvCC ay LnaY!anuary 31 Cl Ivly 18 AecerveC By July 31 <br /> i:A$EE�PLANgTIONr SILLING REMITTANCE ' S REMIT <br /> DATE 1 DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> Ort FEE ��_ gam' <br /> PRORATION __�l__ <br /> V-LIS <br /> PENALT•. <br /> (,THEA I __— <br /> '7 VIHER <br /> 1 � 1/ <br /> L <br /> 1—Nn��7_`2II ��.t. C <br /> 1 No. y� ',H � MnilUa <br /> ° APPLICANT—VMRN AL.COPIES TO: EMVIRONMSN AL n'ALTI l any,caa TOCKTO <br /> - I <br /> " amt a.NAZftTON AVE,P.O.9Pa]Wa aTCC1aTON,CA gS01�F„� y7 <br /> u' <br />