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h <br /> Applications Will Be Processed When Submitted Properly Completed.B• To Sign )iic8 <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable,Revocable.Suspenr' s) f U1.1P&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> al Health District fpr a permit to construct and of install the work harem described This application it <br /> Api,liCahon IS hnrrtby madf•to the San Joaquin Loc <br /> made in compliance with San Joaquin Count Ordinance No IH62 and the rules and regulations of the San Joa wn Local Health Distrix <br /> 3 ,Lt�t ISI �c3 t, y City mown �tAL>ti r <br /> Exact Site Address . 7 �6v y <br /> G�IL A:�r�rVLaGLrl'rT' Phone <br /> J•.vner s Name y City j,C-c/E�..� / <br /> Address .7 <br /> Contractor's Name License p Business Phone <br /> ''r^"" <br /> d'L e� y �f.1 7 Emergency Phone <br /> Contractor's Address .--'' No <br /> Is Certificate o`.Workman' o <br /> s Compensation Insurance on File With SJLHD) Yes 0 <br /> TION❑ <br /> TYPE OF WORK(CHECK}. NEW WELL DEEPEN L RECONDITION 13 DESTRUC ,,f r <br /> WELL CHLORINATION 13 WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION 13 PUMP <br /> REPAIRu <br /> REPLACEMENT❑ Sewer Lines Pit Privy — <br /> DISTANCE TO'DEAREST: Septic Tank <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well - <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> ❑ DRILLED Dia of Well Casing <br /> 13 DOMESTIC PRIVATE Gauge of Casing --- -- <br /> (�DOMESTIC/PUBLIC <br /> 13 DRIVEN <br /> Depth of Grout Seal _ -- ------ " <br /> ❑ IRRIGATION 13 GRAVEL PACK _ <br /> 13 ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION Other Information — - <br /> ❑ DISPOSAL <br /> 13 OTHER <br /> Surface Seal Installed By: -- <br /> ❑ GEOPHYSICAL -N <br /> PUMP INSTALLATION: Contractor HP — <br /> Type o1 Pump _ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: [3 ,late Work Done <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: _- <br /> Describe Material and Procedure <br /> rk will be done in accordance with San Joaquin County <br /> I hereby Certify that I have prepared this application and that the wo <br /> ordinances state laws.and rules and regulations of the San Joaquin Local Health District permit <br /> Homeowner or licen•lid agent's signature certifies the following:"i Certily that in the performance of the work for which this <br /> Is $stied I shall not employ any person in suCh manner as to become subject to workman's compensation laws of California <br /> Contractor's hiring or sub-eontrec!ing signature certifies the following: 'I C"lily that in the performance of the work for which this <br /> permit is issued I shall empic, persons subject to workman's compensation laws of Catiforma' <br /> I will call for a Grout ins,jectlon prior to grouting and a final inspection. / " 5- nO <br /> D Q�w �IFf�,� 1 Title: <br /> �1 a—-z, <br /> rte. Date: (D if <br /> Signa X f( ,+ r° jOraw Plot Plan on Reverse Side) <br /> FO DEP TMENT USE ONLY l �/ <br /> A I CO <br /> T FAppllcai,on <br /> ASE 1 � Ji Date <br /> Accepted By /l+%- <br /> diho^al Comm�nts Phase III Final Inspection <br /> Phase II Grout Inspection Inspection By Date <br /> Dat•` <br /> 1n5;—Cl,m By ❑ S u,.,...,...1 P, L,y-n <br /> ��i i,. ❑ f. ❑ i,• .••, Sax.. <br /> Fee Is Due' ❑ .... ❑ i.. o aMOUNr nUF c..Cf KED <br /> .�. a['fi••eNaF`tit •MOUNT <br /> I.a,f •Fn <br /> f i <br /> 0NA <br /> 35T7 <br /> m f,�� <br /> n•.• <br /> • ... .... JWIF HAMTUN AVF PO no.?*" sTOCNTON CA""I .. <br /> APPLICANT-R[TUPN ALL CC' TO fNVIRONM[NTAL Hf ALTH Pf RMIT%FRVIC[S <br />