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.iU <br /> APPI "a Will B P sIyOFOR OFFICSUSE: U <br /> nSbmltled Properly Completed.Be Sure To Sign The Application. <br /> 1! <br /> APPLICATION <br /> I (For -Transferable,Revocable,Suspendable) <br /> SAN JOAQUIN ILL 4L PUMP&WELL <br /> HEALTH D14WYL�PNMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to theSan Joaquin Local Health District fo•a permit to construct and/or install the work herein described.This application is <br /> made In compliance with lian JQaq"Count Qromance No. 1882 and the rule,and regulations of the San Joaquin Local Health District. <br /> Exact Site Atldreu �C/ �Gj. _J�.�.r.., M� <br /> City/Town <br /> 5`r'# Owner's Name <br /> Phone.-1'_.L(—J/�I—Contractor's <br /> — e City_AZt___P - . <br /> '. Contractor's Name ¢yi r �i / License p_ _ D <br /> fl-=�2t —a <br /> Business Phone <br /> Contractor's !_41 <br /> n.l... Contractor's Address Ej _ Emergency Phone - <br /> la Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ <br /> NO�. .._0__ r' TYPE OF WORK(CHECK): NEW WELL DEEPEN 13RECONDITION❑ DESTRUCTION ' <br /> WELL CHLORINATION❑ WELL ABANDONMENT 13 OTHER 13 PUMP INSTALLATION 13R __0PUMP REPAI <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 13 CABLE TOOL Dia.of Well Excavation----_____ <br /> O DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> 0 DOMESTIC/PUBLIC 0 -- -- <br /> DRIVEN Gauge or Casing <br /> 0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> O CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> C3 DISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL guAag9 Seal Installed By: <br /> PUMP INSTALLATION: Contractor GAJ'/S><.rlrr-rr <br /> Type of Pump S H.P. <br /> _ <br /> PUMP REPLACEMENT: ❑ Stale Work Done_ (� ; <br /> PUMP REPAIR: 0 State Work Done T _ <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 will!San Joaquin County .' <br /> y. ordinances,state laws.and rules and regulations of the San Joaquin Local Health District. e•O <br /> Homeowner r licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued. 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-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit i3 issued,1 shall employ persons subiect to workman's compensation laws of California." <br /> for Gr SPeeilon prior to grouting and a final Inspections �( <br /> Signed X _ doLL—^-- Title: —.J��,/�•�J/ Date: <br /> S (Draw Plot Plan on Reverse l0e) <br /> FO EPA MENT U ONLY <br /> PHASE I �� //�$E <br /> y. Application Accepted BY 'N / —_——D7:!� <br /> �2/�� <br /> z Additional Comments: __ <br /> Phase 11 Grout Inspe4ction Phase 111 Final Inspection <br /> Inspection BY Date_______ InsZBy. —. Date <br /> Fee Is Due:❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑EACH ❑ Jary January 3l July 16 Recened By July 3I 91LlING REIAITTANTAPSE I ExPLANATION AMOUNT DUE CHECKED <br /> DATE DATEDFEE �st �� AMOUNTLESSAFICA TIONIFIN LVV <br /> PLUS <br /> ____ <br /> OTHER <br /> I ,r- <br /> OTHER _--.— ..._ <br /> i t <br /> _ 3 a-- -c_s ss s �d <br /> -- --- -- - <br /> RKOrq ey Dole RKe'PI Na Perme No Ixusrlca Daie ManeO pain vee <br /> AMLKANT—RETURN ALL COMES TO: ENVIRONMENTAL HEALTH PERMIVSERVICES IWI E.HAt LTON AVE..PO.eoa tea, STOPKION.CA 9at91 <br />