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Appl;cnllons Will Eja Procei;23(fj When Sul:rr,!INW Properly Complatod. be Sure To Sig i The Application. <br /> "DR OFFICE USE: <br /> .A?RL i C AT i C, <br /> Ii�'or Non-7ranseraziu, Sold l PUMP&WOF�PLi_Tt ;N ELL <br /> AT E. WAW2"UhLITY <br /> is herety madr,!,)the San Joaquin LOC31 Health District fora p-irmil to construct and/or i%lafl <br /> , <br /> thework herein described.This apptication iscompliance W;!r Jc:IGuinC nI Ordinrce 462 <br /> and.'h rules and regulationsof the Sa loaquin LOC41JAealth District. <br /> C <br /> own <br /> ,it, <br /> .;Ict Site Address y'Town <br /> Nairla <br /> �rldress Prionn <br /> Cll',tractor's Name Bus hcity-,: <br /> rm PP <br /> hone <br /> ro-tractor's Address <br /> Emergency Phone <br /> Ce,tificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> 'YPC OF WC—K CHECK): NEW WELL 0 DEEPEN 13 RECONDITION 13 DESTRU0710NO <br /> NPLL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER 13 PUll INSTALLATION ED PUMP REPAIR 13 <br /> ­E r <br /> PLACEMENTO <br /> DISTANCE TO NEAREST: Septic Tank 4P Pit Privy -- <br /> 1, >,ewer Lines—1 — I <br /> Sewage Dispose, <br /> Ces3pool/Seepage Pit <br /> Other <br /> Property Line-4.2—Private Domestic Well.X Public Domestic Well <br /> INTENDED USE ;YPE OF WELL <br /> -I L :NDLjS7R!AL LADLE TOOL Dia.of Well Excavation <br /> 1 <br /> .77 -)CMEST;C/PRIVATE DRILLED Dia.Of Well Casing <br /> DOMESTIC/PUBLIC Lj DRIVEN Gauge Of Casing <br /> EJ IRRIGATION <br /> GRAVEL PACK Depth Of Grout SZ <br /> a / <br /> J CATHODIC PROTECTION 13 ROTARY Type of Grout <br /> DISPOSAL OTHER Other Informal' n <br /> LJ taller <br /> GEOPHYSICAL /11 — <br /> Surface Se installed By: <br /> -IUMP INS7 ALLAY. <br /> Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP KH;rLACCWEXT: LS tate Work Done <br /> R 2 P.Ak I P: U Stale Work Done <br /> Weil Diameter Z2- <br /> Approximate Dep h <br /> Describe Material and Procedure <br /> 1 hereby certify tinat i hava pre-pared this application and, that the work will be done In accordance with San Joaquin County CPI <br /> c;rdinaricas. 31:1ic laws,and ruies ani •egulations of the Sar.Joaquin Local Health District. <br /> Homeowner or;lconz&e aili, 2ho Joilowl,,IZ:"!certify that in the performance of the work'forwhich this permit <br /> is issued, 1 shall not employ any perion in such manner as to become subject to workman's compensation laws of California." <br /> Z;;;mlractor'7..(ring or sub-contiractin-.iiiianalure corlillea the fol:oIlil"I certil-y that In the performance of the work torwh*ich this <br /> po..-mi',is issued. I shal!employ persons subject 10 workman's cornpensation:aws of California <br /> In e ;L <br /> r�:tf cast �ir �v <br /> Q N '%P;Qr to groul Zing and a if,ta!inspection. <br /> TWO: <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPAATML-N-d USE ONLY <br /> N <br /> PHASE <br /> C <br /> Application Accepted Date <br /> Additional Comments:.---..- <br /> Phase 11 Grout Insp,=ion 11 F1 tlon <br /> Inspection By­- <br /> Odle Inspection By 6��, <br /> Date <br /> Fee 13 DUO: [3 ANNLALLY ❑ PER UN;T U PER SITE ❑ EACH <br /> July I d Reci-wea b/July 31 <br /> EXPLANATION 81:,L;NIG RE.Vi TTANCE REMIT- --- <br /> DATE DATE RENI.i7TEG AMOUNT DUE i CHECKED <br /> AMOUNT <br /> rt' <br /> • OQ <br /> FEE 7:> <br /> LEIS <br /> PRCt,ATIO i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Roce—',DY <br /> Dal,. P*!M�l NoIFnsuance Lai.) <br /> APPLiCANT-AETURN ALL COPIES 46J7 d.WAXiIi.-CM AVZ.,P.O.Liax 2,49 670CI(TON,CA 4116201 <br />