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i - Applications WNI Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicat'iba <br /> OFFICE usE: APPLICATION ' a— <br /> S J- (For Non-Transferable,Revocable, Suspendable) -� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> �+ <br /> 'COMPLETE IN TRIPLICATE) '. WATER QUALITY <br /> I%Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described,This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address I M5, IV h4u/.ty 9� - City/Town Ofif w? sRo <br /> Owner's Name /i1.44 TE8E55/ Phone 334— 3750 <br /> Address — /g9/S i✓ /�/[ ✓ 9� City ♦%CdAw9k9 <br /> r Contractor's NameI wr Licenses 33 JOIs`Geueimss Phone 7S-V—3377 <br /> Contractor's Address �/3BY' "_11st ,,..—. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJ HD? Yes No <br /> TYPE OFWORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITIO DESTRUCTION 13 �} <br /> WELL C LORINATION ❑ WELL ABANDONMENT❑ OTHER 0 PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLAC MENTI] � <br /> DISTANC TO NEAREST: Septic Tank /rjO Sewer Lines /� Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Ogrer <br /> Property Line,. y Private Domestic Well�_rPublic Domestic Well <br /> INTE DED USE �� aIRll1 TYPE OF WELL ; <br /> ❑ INDU RIAL pr CABLE TOOL Dia.of Well Excavation <br /> ❑ DOME TIC/PRIVATE r ❑ DRILLED Dia,of Well Casing aYr� /$A rA&9MWZW /O'• <br /> ❑ DOME TIC/PUBLIC M ❑ DRIVEN Gauge of Casing /06®--- <br /> JR IRRIG TION ❑ GRAVEL PACK Depth of Grout Seal A(e t<_ �— <br /> ❑ CATH DIC PROTECTION A ❑ ROTARY Type of Grout__ ' <br /> ❑ DISPO AL ❑ OTHER Other Information <br /> ❑ GEOP YSICAL !. C ce Seat 1 tailed By: 6Y/:E2!2 Bj <br /> PUMP IN. <br /> ALLATION: Contractor UR��)✓ <br /> Type of Pump H.P. od <br /> PUMP RE LACEMENT: ❑ State Work Done --� <br /> PUMP RE AIR: '� ❑ State Work Done <br /> `IESTRUC ION OF'WELL: Well Diameter Approximate Depth . <br /> ;I Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> rdinances,state laws, and rules and regulations of the San Joaquin Local Health District, <br /> Drive owner or licensed agent's aignsture certifies the following:"I certify that in the performance of the work forwhich this permit <br /> s issued• I shall not employ any person in such manner as to become subject to workman's compensation laws of California." i <br /> ntractoes hiring or sub-contracting signature certifies the following;1 certify that in the performance of the work forwhich this <br /> rmit is issued. I shall employ persons subject to workman's compensation laws of California." <br /> wii all for a r ut nspection prior to grouting and a final Inspection. <br /> Signed X - - Title: _ 1 -Date: . <br /> (Draw Plot Plan on Reverse Side) - •1 <br /> FOR DkPARTMENT USE ONLY T <br /> PHA E 1 d �� <br /> Appli ation Accepted Data <br /> Add, onal Comments: Jl E • - 3 <br /> Phase/[l r sut 1 Bon 111 Final Inspection ( i <br /> 1 on 6Y---P Date Inspection 8y � ��re~L, r�� yrp r <br /> Fee DBat-O ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACFI ❑ JEnwry 1 a Received BY nuary 31 ❑ JuIY 1. t 2 e7 By JUIY 3t <br /> BILLING REMITTANCE f E <br /> BABE 4 EXPLANATION DATE DATE REMITTED AMOUNT DUE CHHECCKEKE <br /> D <br /> AMOUNT <br /> FEE Q L <br /> PESS <br /> R ON <br /> PLUS d <br /> PENAL <br /> OTHE � t <br /> OT <br /> 13q o ,;* <br /> byDere d R~Ni,. Pe m 1 No. N. ma oel rated <br /> T—RETUMI ALL COPE*TO: BMNOMERMf HEALTH ME /SERVICES 1Mt E-NAffiTON AVE.•P-0.OM MM STOCKTON,"96H) / <br />