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Applications WIII Be Processed When Submitted Properly C tff.{ S � ne cation. <br /> FOR OFFICE USE: APPLICATIO 333LL3le <br /> (For Non-Transferable,Revocable spendable) P &WELL <br /> ENVIRONMENTAL HEALTH'PER 24982 <br /> (COMPUTE IWTRIPLICATE) WATER QUALITY 4. <br /> n <br /> Application is hereby made to the San Joaquin Local Health District fora permit to afFl ��+adescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the,rules and reg1f�` 1?1.T fhe-Sa-1 quJn Local Health District. <br /> Exact Site Address 4;7 Z'/ City/Town <br /> <tr <br /> Owner's Name _-AWt7>7-- Phone <br /> Address •7)b <br /> City— <br /> Contractor's <br /> Contractor's Name }��'• ' License# Jl �`3X3 Business Phone <br /> Contractor's Address •a• Emergency Phone `� �`• ' <br /> Is Certificate of Workman's Compensation Ins ance on Fite With SJLHD? Yes No 'r <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ ' RECONDITION❑ _ DESTRUCTION -: r <br /> WELL CHLORINATION ❑ • WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT fr <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy / �. `>;;f• .f. <br /> Sewage Disposal Field Cesspool/Seepage•P..it r Oilier <br /> Property Line Private Domestic Well Public Domestic Well "`:r= r t <br /> INTENDED USE TYPE OF WELL <br /> f y ,�_ <br /> j..r hIt `p <br /> A. _ �' <br /> 0,4NDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation'�; J( j� <br /> 13 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - -` G ` t <br /> 11DOMESTIC/PUBLIC DRIVEN Gauge of Casing 1 't '' F+ ; <br /> # �'• 'j , <br /> ❑ IRRIGATION ❑,GRAVEL PACK Depth of Grout Seal - <br /> ❑ CATHODIC PROTECTION © ROTARY Type of Grout ' `J <br /> ❑ DISPOSAL ❑ OTHER Other Information "'r <br /> 11 GEOPHYSICAL .- . <br /> Surface Seat Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ► tr` ; <br /> PUMP REPLACEMENT: -- State Work Done <br /> PUMP REPAIR: ❑ 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 <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agentVsignature certifies the following:"I certify that in the performance of the work for which 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 for which this , <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." t <br /> will call for a Grout fnspection�prior to grouting and a final inspection. a <br /> Signed X (A!,� )77. h wv✓' £. f. fin',:+�,- Title: � aP�a- 4j Date: r1.3_ _ 1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE! 08 <br /> Application Accepted By Date S� <br /> Additional Comm <br /> se rout inspection7, e n / <br /> Inspection Date a Inspection By e <br /> Fee Is Due! ❑ NUALLY ❑ PER UNIT" 1:1 PER SITE 11 EACH ❑ January 1 & e ved By January 31 CJJuly t 8 Received By'July 31 - <br /> REMIT <br /> J BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �'�., A(AOUNT <br /> FEE <br /> LESS _ <br /> PRORATION e <br /> PLUS r • <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Po it Nn mijance-oate Mailed ._ Delivered <br />