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- .�'� � r ,. Applications-4Vfll Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> J . :FOR.+OFFICE USE: APPLICATION- <br /> (For Non-Transferable,Revocable;p�� I �-- <br /> `H�ERhA PUMP WEEL <br /> • ENVIRONMENTTpAAL MAI <br /> (COMPLETE IN TRIPLICATE) Wa'C'v "" ,,CL� . <br /> 1. <br /> Application is hereby madetothe San Joaquin Local Health Dist rict +' Iffftttoconsttrruc��t!(�fI r Install the work herein described.T is application is <br /> made in compliance with San Joaquin,CoIllLiimy�/Ordinance No. 186 1 he rule`s\ a p:�gulations PLv&.San J aquin Local Health District. <br /> Exact Site Address� �5..7 /1�s-��+ GCTn J��fi�^� <br /> C�PCi \Phone <br /> Owner's Name zot-ir A2 <br /> Address Ci r3 S S 741. 1r 1 tjp�-fir City <br /> Contractor's Nam s�4,.a/ License 0= 3 1Business Phone <br /> Contractor's Address Emergency Phone _ <br /> Is Certificate of Workman's Compensation I surance on File With SJLHD? Yes e� nOtther <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCT / <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOR <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well <br /> -- INTENDED USE TYPE OF WELL <br /> + ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> { ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 1 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION .❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ tate Work Done - <br /> PUMP REPAIR: tate Work Done Agtala-/ -�n`N'� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 /> k Contractor's hiring or sub-contracting signature certifies the following:"I certifythatin the performance Of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final Inspection. <br /> f7- el <br /> Signed X "A.r.L ('n. C ., G f ni i o�eJ� .Title: (� AA _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I Q -Z <br /> Application Accepted By ' Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 Final inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 s Received Byl July 31 <br /> REM <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED A NT <br /> j FEE <br /> LESS �D <br /> ( PRORATION <br /> PLUS Y ./NGG✓ <br /> PENALTY _ <br /> OTHER �y r <br /> 1{ OTHER �y / <br /> r Received by Date Receipi No. Permit No. issuance to D Ma led Delnired <br />