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Applications Will Be Processed WhenEub"Aled Properly Completed,Be Sure To sign The Appocamm. <br /> " <br /> FO OFFICE USE" I ' n APPLICATION <br /> �•,6jm <br /> Y (For NIRONnsl NTA Revocable,SusERMI le) PUMP&WELL 1 <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> 10 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 6 <br /> � . Application is hereby made loins San Joaquin Local Health Districtiora permitio construct and/or install the work herein described.This application is <br /> 111111 made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San JoayulJl Locpl District. <br /> Exact Site Address 4uI04 ai A4 Xlf= City/Town a3•fp i �-- <br /> r� / (I Phone <br /> Owner's Name EO'I CO fat Ire�T n - <br /> !(.Q/1�—� '���! City <br /> Address <br /> LicenseMfftf-Business Phone ALL '7Lu <br /> Contractor's Name <br /> Cdntractofs Address Emergency Phone <br /> ! Certificate of Workman's Compensation Insurance on File With SJLHD? Yea_mss— No <br /> TYPE OF WORK(CHECK): NEW WELL C3 DEEPEN 13 RECONDITIONO DESTRUCTION❑ <br /> I WELL CHLORINATION D WELL ABANDONMENT O OTHER D PUMP INSTALLATIONS PUMP REPAIRO <br /> REPLACEMENTO <br /> DISTANCE TO NEAREST: Septic Tank Sewer Linea Pit Privy <br /> Sewage Disposal Field .Cesspool/Se6pa9e Pit Other <br /> (.. <br /> Property Line.Private Domestic Well Public Domestic Well , <br /> INTENDED USE TYPE OF WELL <br /> O INDUSTRIAL D CABLE TOOL Die.of Well Excavation <br /> JM DOMESTIC/PRIVATE D DRILLED Ola.of Well Casing - <br /> D DOMESTIC/PUBLIC <br /> O DRIVEN Gauge of Casing <br /> 1I ❑ IRRIGATION O GRAVEL PACK Depth of Grout Seel <br /> Y O CATHODIC PROTECTION D ROTARY Type of Grout <br /> r13 DISPOSAL D OTHER Other information <br /> D GEOPHYSICAL Surface Seal lied By: <br /> ( PUMP•INBTALLATION: Contractor H.P. <br /> P <br /> I Type of Pump on�— st f f <br /> PUMP REPLACEMENT: � 0 Stele Work Done �E � A <br /> PUMP REPAIR: D State Work Done <br /> f Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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,stale laws,and rules and regulations of the San Joaquin Local Health District. <br /> Nome owner orlicensed agent's signature cartllles the following:"I certify that in the peAormanceof 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 Caliiorme." <br /> Contractor's hiring or sub<unlrscting slgnaturs cerliflea the following:"1 ceroty that in 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 /> wit call for a Grout looped a if to rdL Ing♦s N q final Inspection. <br /> ,i <br /> Signed X� <br /> 1 Plot I`YAF�IIIn T 'fes✓ n OaM: /Y <br /> j (Draw Plot la on Reverse Side) <br /> r <br /> r FORD PARTM NT USE ONLY <br /> PHASE J <br /> l Application Accepted By Data <br /> i Additional Comments: -- <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Inspection By_ Date Inspection By Date <br /> �. Fee Is Dae:D ANNUALLY ❑PEP UNIT PER SITE D EAOH D January t 6 flNelved my January]1 ❑Jury I a R elwRaEBa Tuly]1 <br /> 1 BABE E%PLANATION BILLING REMITTANCE E AMOUNT DUE CHECKEO <br /> DATE DATE REMITTED AMOUNT <br /> FEE J <br /> LESS <br /> PRORATION Q 1 <br /> PLUS <br /> PENALTY <br /> OTHER '1`yfk \ <br /> OTHER <br /> bb <br /> IflecaNea W 0- r 'Muaa DlN.ac <br /> APPLWAMt—PETaPN ALL COP1et T0: ENVIRONMENTLL NCALTN rtRMIT/sERVICE4 —1WIEHASELTONAV[.,RO.aoa%M STOCKTOH,CA"CP— <br /> as <br />