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A,pplioations Will Be Processed When Submitted Properly _Completed.Be Sure 7o Sign The Application.. <br /> FOR OFFICE USE: APPLICATION <br /> r' <br /> -. t (For Mon-Tmnsterable,Rev;cable,'Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> •(COMPLETE IN TRIPLICATE) <br /> WATER QUALITYApplication is hereby made to the San Joaquin Local Health Districtfora Permitto construct,and/or install the work herein described.This application is <br /> made in compliance with San Jeaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_y `�(y�"/�'" !A / F,n <br /> Owner's NamePF0 <br /> City/Town jtS'r,NiLi/" <br /> !)P�4 <br /> Address $ r Phone <br /> Contractor's Name GNI U/}7 fip City <br /> -- L_= nP� /Y/ License tt <br /> Contractors Address ��n S'.. Kl/ ppy Business Phonea, -799,�J <br /> Is Certificate of Workman's Compensation Insurance on File <br /> D' erg Yes No <br /> Phone <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN Q RECONDITION Q DESTRUCTION0 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ - rrI�� <br /> REPLACEMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR0 <br /> DISTANCE TO NEAREST: Septic Tank v/W <br /> r'�Vl <br /> �W�L Sewer Lines Pit Privy <br /> Sewage Disposal Field .�G(t <br /> Property Line --- Cesspool/Seepage Pit Other <br /> INTENDED USE -`�--Private Domestic Well ZJW Public Domestic Well <br /> Q INDUSTRIAL 'i TYPE OF WELL <br /> S.DOMESTIC/PRIVATE 17 CABLE TOOL Dia.of Well Excavation_ <br /> Q DOMESTIC/PUBLIC 13 DRILLED Dia.of Well Casing r <br /> Q IRRIGATION El DR (O <br /> IVEN - Gauge of Casing Pyc ! <br /> Q CATHODIC PROTECTION . GRAVEL PACK Depth of Grout S.ppe�alX,,,�77 �• <br /> Q DISPOSAL R-ROTARY Type of Grout -g{ffde7i ' '1ZE a <br /> GEOPHYSICAL OTHER <br /> ------___ Other Information <br /> PUMP INSTALLATION: Surface Seal Installed By: <br /> CODtraCSOr <br /> PUMP REPLACEMENT: Type of Pump <br /> � State Work Done H.P. <br /> PUMP REPAIR: 4 <br /> �STRUCTiON OF WELL: 11 State Work Done <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth , <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, Q <br /> Home owner or licensed agent's signature certities the following:"I certify that in the performance of the work forwhich 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." t <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that In the performance of the work for which this <br /> permit is issued. I shall employ persons subject to workman's Compensation taws of California." <br /> I will call for Grout Inspection prior to grouting and a final inspection, <br /> Signed X '� �^ �/ <br /> Title. <br /> IS/ (Draw Plot Plan on Reverse Side) Date: <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI � - ) <br /> Application Accepted By �>t,p„ O L <br /> Additional Comments: Date <br /> ase II Grout inspeeticn <br /> Inspection By Date "7--Z.R s�Z Phase 111 Final Inspection <br /> ,Inspection By Date <br /> Date <br /> Fee Is Due:Q ANNUALLY [] PER UNIT 1 17 PER SITE EACH <br /> �— <br /> QEACH ❑ Jdnuary 1 8 Rec¢ived By January 31 '❑ July/a Receiv¢d ay July 31 <br /> BASE t <br /> EXPLANATION - BILLING REMITTANCE g REMIT <br /> 1 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER ¢¢ <br /> Received by Det. ReceipS ✓ �� <br /> -ONME1 NO Permit No, <br /> APPLICANT— <br /> RETURN ALL COPIES TO: ENVIRONMENTAL NEALTN PERMIT/eERVICEs � I ane¢Dale Mailed ' Delivered.. <br /> 1M E.NAZELTON AVE.,P.O.ll r aeo, 61 OCKTON.CA 6Eae1 1a.. <br />