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-- - N <br /> Applications Will Be Processed When Submitted Properly Completed.Be sure 10 tagn 1 ne <br /> gn- <br /> APPLICATION <br /> (For Non-Traneferab(e,Revocable,Suspendable) ' pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT�IIA� UALITY. .(COMPLETE IN TIPLICATE) t2G-t.fSG -5• Pil-TtVIA 'a 't"'1 ?^ °� d! <br /> Application is hereby made to the San Joaquin Local Health District for"aper lto construct and/or install the work herein describe This application is <br /> made in compliance with San Joaquin ount Ordinangello�,1$62 and they�les and r talions of the Sen J aquin Lfo Health District. <br /> q y r. .7�jSp r �, <br /> I Exact Site Address ^ ^ T e4nty nen r.r' 1 [xff r� City/Town �/ T�, ,. <br /> c Owner'sWame . ._., . ;. .. -Phone- <br /> Address <br /> Phone-.. •e <br /> lh `- � ' <br /> i'.a:, . •N:" 'r' v✓`• .xs 'City �.. <br /> r � <br /> Contractor's Name `` `License#' ,Z 7.1 Business-Phone" '�Z� Q2 <br /> n <br /> Contractor's Address <br /> 9 _ -St r, n+, •"Ertiergendy.Ph ne ^ r.._. .J.- 1fF.[Sn. <br /> Is Certificate of Workman's Compensation Ins rance on File With WLHD? Yes No <br /> TYPE OF WORK(CHECK): � NEW WELL DEEPEN ❑ '• REC NDITION DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ I Pl1 4' do. . <br /> 'i Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank - � Other <br /> Sewage Disposal Field �— Cesspool/Seepage Pit <br /> Property Line �� Private Domestic Public Domestic Well . <br /> - INTENDED USE TYPE OF WELL y <br /> ❑ INDUSTRIAL % "' <br /> ❑ CABLE TOOL Dia. of Well Excavation_ <br /> 7 ❑ DRILLED Dia, of Well Casing ^" <br /> OMESTIC/PRIVATE - ._ <br /> DOMESTIC/PUBLIC ❑ DRIVEN y Gauge of Casing <br /> ❑ IRRIGATION E3 GRAVEL PACK - Depth of Grout Seal <br /> 13 CATHODIC PROTECTION ROTARY Type of Grout . <br /> ❑ DISPOSAL 11OTHER ' Other Informat �. <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . . . <br /> Type.of Pump _ H.P. <br /> PUMP REPLACEMENT: ❑ Statiwc� rk Done - <br /> PUMP REPAIR: ❑'State Work Done <br /> 'I <br /> Approximate Depth <br /> DESTRUCTION OF Well Diameter 'WELL: - <br /> Describe Material and Procedure - <br /> t _ <br /> I hereby certify that I,have prepared this application a'hd 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 /> Home owner or licensed agent's signature cergties the following:"I certity that in the performance of the work for which this permit <br /> ensation laws of California." <br /> is issued, I shall not employ any person InSuchmanner as to become subject to wdrkman's;comp <br /> Contractor's hiring or,aub-contracting signature certifies the following:N certify that in the performance ofthe work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation <br /> laws of California.'.'- <br /> permit <br /> will call for a Grout InspectIon prior to grouting and a final inspection. <br /> Signed X ( Title: Date: <br /> - <br /> , I (Draw Plot Plan on Reverse Side) I <br /> FOR DEPARTMENT USE ONLY - - <br /> PHASE 1 <br /> 4� //��pl{�1� ttel'Yflfl I <br /> r <br /> '+ rDa'. <br /> te <br /> Application <br /> Additional Comments, 8haIaal Inspection <br /> phase 11 brout-Inspection ! <br /> %_ <br /> Date Inabection By K - •-Date <br /> ,tnspectlonBy. A-% t3s+1 Apf'" /?+ 2 �Ff�y/ f)/�' <br /> Fee Is Due: ❑ ANNUALLt�., 9ER'UNIT° PER TE ❑ EACH, January i Il6ved By']anua,y 31 h ❑ July 1 8 ReceivedREMIT <br /> uIY 31 <br /> - A .• BILLING REMITTANCE .s AMOUNT DUE CHECKED <br /> BASEEXPLANATION DATE DATE REMITTED AMOUNT <br /> FEELESS <br /> y <br /> PRORATION <br /> PLUS - - - <br /> PENALTY <br /> OTHER <br /> OTHER .. .. } <br /> l <br /> ., _....w Data ..•ReeelDt•No. - .•o- Permit No. - - 1 uen Data) s^Mall�•,me Delivered <br /> __ amnKTOeTON.CA 95201 � <br />