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y <br /> Appli"Bbbs Wil1.l Be.PLocessa_d When SlUbmilted Properly Completed.Be Sure To Sign The Application. \- <br /> FOR eFFlcz L 1 - ': . APPLICATION rim%. oc <br /> A (For Non-1 ransferable.Revocable,Suspendable) <br /> SPT J' �r,'i.: IO: nL PUMP&WELL <br /> 1 HE, E)JNVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San.loegdm Local Health District fora permit to corstruct and/or install the work herein described,This application is <br /> made in compliance with an Jpaq U+\4=Count 9rd,nance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address a L'�CJ �+"_� 5l� 7 !iT City, A%o <br /> 'Town l 71C 1 <br /> Owners Name !/ _.�J! --C!i't>�-}^2-� Phone �- (•-' ,�/ _.__.O�-. <br /> Address _�.iJ .� -,-��J-��avat. dS iJJ_. _ _ .. . _. _. City- ._�'fC <br /> Contractor's !,) <br /> sName y .PJ_E��cC'1_rtC / 9E/1� ��!� License# Business Phone_ ?.A3 <br /> Contractor's Address Address {� L /�C.1' ..7�.Fi _ Emergency PhoneIs Certificate of Workman's Compensation Insurance on Pile With SJLHD9 Yes No <br /> TYPE OF WORK (CHECK) NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTiONO Q <br /> WELL CHLORINATION❑ WELL ABANDONMENT O OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRZ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _. Pit Privy <br /> Sewage Disposal Field .. Cesspool/Seepage Pit Other <br /> Property Line. -- _ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia.of Well Excavation . — <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Wall Casing <br /> ❑ DOMESTIC/PUBLIC O DRIVEN Gaugeol Casing <br /> 0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> C3 CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> GEOPHYSICAL �q LSurface/Seal Installed By <br /> PUMP INSTALLATION: Contractor jJ -_ ­��'< I,'_� <br /> Type of Pump '_. ._ _/ H.P <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: 0 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 A <br /> ordinances.state laws.and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that e,the performance oft-. - -.rk ronvhich this permit <br /> is issued. I shall not employ any person in such manner as to become subject to workman's r-Ompef.011Ln I:.ws of California.' <br /> Contractor's hirirj or sub•contracling signature certifies the following:"I certify that In the performance of the work for which Iris <br /> penmt a Issued, I snail employ persons subject to workman's compensation laws M California." <br /> I willca for's G,0944spection prior to grouting and a final inspection <br /> Signed X . / _sz".: Title: _ F)a✓t- �y.1�/ Date: <br /> v Plot Pfau on Reverse Idel <br /> FFDEPAR MENT U$E ONLY <br /> PHASEI //, / <br /> Applicabon Accepted BY �� �- 'f✓`r...-// Date <br /> Addlbonal Comments: <br /> Phase II Grout Inspection ! Phase 111 Final Inspection <br /> Inspection By Dale Insoecbci: By Dale <br /> Fee Is Due:C1 A'uulALLv ❑ Prn Ulu: ❑ r,tii•.i1F ❑ rA,.,. G J­„,I JxnPen]I ❑.n,i.,16 R.•ce�..,IR p9 J.”,al <br /> m REMIT <br /> 9>4E _xPI ANAT10% ELL.N11 RFVrt IANC[ t AMOUNT DUE CHECKED <br /> roVE OA rF NEMITTEp L, AMOUNT <br /> FEE ..5 <br /> LESS <br /> PRORATI.'. <br /> PLUS ( - <br /> PENA..TT <br /> HEn <br /> De. P..r,..q.: I.m.nr,Doh. Maawn O,.I n,....I <br /> ..•PLICANT-RETURN ALL COPIES TO. ENVIRONMENTAL HEAL'H PERMIT 9ERVV'Es 16x1 E HAZELTON AVE.,PO,Sam Axis STOCKTON.CA 95201 1 <br />