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tif . <br /> nryoliealinns WIII Fie ProeesAad When Submitted QrapeHY Completed•Be Sure 7o sign The Appf kaon. . <br /> APPLICATION <br /> ,; ��: ti;t:. �nsjpectlNor� <br /> (For Nor-Transferable,Revocable,5uspendeble) PUMP&Vf/EL <br /> 13 <br /> ENVIRONMENTAL. HEALTH PERMIT s < <br /> -f- WADER QUALITY �?� M�. i L' <br /> }Pf.CTFINTRIPLICATE) �� f Joaquin <br /> w. ealthDist . it000nsiructandthrin althewo►khereI escribed, hit appHCal�1l <br /> +:.�f4�s�y,+sale to the San JoaUuin Locat Health District for a pe.m t �� <br /> r:re x{ir,San Joaquin GoLrnry Ordinance No. 1862 an,!the rules and reg»iattons of she San Joaquin Local FtnDit t <br /> n7dress S,tt� -CC�RAlE1�_3ANA1aT d SAGk.�ONE-_. ....___ __. City/Town__ -- -w- -i '—w-- <br /> Phone <br /> city_:_RCArt1P0 �fiEAj,:;� -pIST <br /> �c;pr's Name �E�}R11sG.�UCtt1P_}.TRRtCo�S�1©►.1 License113M075-1 _ Business Phone�12�1-�5�1.8 <br /> ittr.-s Address}'1'1'.5�_t1•_NWY..gBt Lk D._---_._- _ Emergency Phone <br /> 'art nc,gt�+ol.Workman's Compensation Insurance on rile With SJLHD? Yep-_� -__ NO <br /> Tvr'F OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> j <br /> E:'Ll L CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑" <br /> :.' PLACEMENT❑ <br /> r':{ 1 aNCE TO NEAREST: Septic Tank .. Sewer Lines— n-__-_ _ Pit Privy <br /> Sewage Disposal Field._ - Cesspool/Seepage Pit-. _,..____. Other------------------------------- <br /> - <br /> Property Line- _:�Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation_ -- -- x <br /> ❑ DRILLED Dia.of Well.Casing <br /> --y OOMESTIC/PRIVATE L] DRIVEN Gauge of Casing —_—. - - � <br /> � CtCil~4t=:STIC;PUBLIC <br /> '?_5'iRRiGAT10N ❑ GRAVEL PACK Depth of Grout Seal- <br /> U t:%-,HODIC PROTECTION ❑ ROTARY Type of Grout <br /> i-t Di_gPOSAL ❑ OTHER other Information <br /> ❑ GEOPHYSICAL Surlace Seal Installed By: <br /> PIMP INSTALLATION: Contractor G.OP _Ln <br /> Type of Pump St.]L] --- M.P. <br /> PUh1P REPLACEMENT: ❑ State Work Done-. - <br /> PLIMP REPAIR: ❑ State Work Done, <br /> DE:;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materiai and Procedure - - --- -- <br /> .� <br /> I hereby certify that; have prepared this application and that the work will be dona`In accordance with San Joaquin County <br /> ordinances,state laws;and rales and regulations of the San Joaquin Local Health District. D <br /> Home owner 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 shalt not employ any person in such manner as to become subject to workman's compensation taws of California." <br />^' Contractor's hiring or sub-contracting algnalure Certifies the following:"t certify that In the performance of the work for which this <br /> permit is issu , I I employ persons subject to workman's compensation laws of California," <br /> r= I will cat( in ctlon prior to grouting and a final inspect <br /> I _ Title: Date: �� 3 <br /> Signed x --�., _ -- — - _ - _- <br /> (Draw Plot Plan on Rever?_Xds) <br /> FOR DEPARTMENT 115E ONLY <br /> IY <br /> MMS PHASE I - fj(� � 9"4J <br /> Application Accepted - <br /> Additional Comments: <br /> ' Phase 11(trout Inspection ase t0 F 1 on tl� <br /> Inspection By—.—__ Date_ - ----_._.--._.. inspection By -• T ��� <br /> h <br /> Fre IS Flue: ❑ ANNUALLY ❑ PER UNIT - ry❑ PER sITE.r,My❑EACH 0 Janoery 1 a Received By Ja _ry 31 ❑ Jwty S RecwivMl By July 31 <br /> �•�' -- <br /> BASE --—• EXPLANATION BILLING REMITTANCE f AMOUNt OL'E CHECKED ' <br /> DATE DATE REMITTED AMOUNT <br /> Aim <br /> _ S - <br /> rstto V7wi'mp1 Na .._. Pnrmrt Nn latus a thn---"Me1Md» —"--�Dalrveeed <br /> �I �,;^n•t!---nr TklraN ALL CONE',Tk`. ENVIFIONMENTAL MEALYM PtAMIT19eRYIr:FA toot E.t1AIELTON AVE..P.O.Ow MN aTOCKTON.CA k17111 ' �, <br />