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Applications Will Be_Procds d When Submitted'ProPerlY Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> f 1 tG►+�o�e (For Non-Transterabia, Revocable,Suspendable) PUMP&WELL <br /> Le <br /> ENVIRONMENTAL HEALTH PERMIT <br /> QUALITY <br /> (COMPLETE IN TRIPLICATE) WATER Q <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wlth-San_Joaquin CountyJOrdinance No.1862 a th r les�rl *VO, San'Joa in veal Health District. <br /> Exact Site Addres sGa.f7 � j- f I , �.,� <br /> Owner's Name Cr�~f�e.t Rfd JR&4 4a r-Zmo►m�i A ones n Phone <br /> Address r City . S!4i?m!"� <br /> Contractor's Name Seo �L/ . Z.� License#Y 2,3-72,4-- Business Phone i467- —7674 f <br /> Contractor's Address a6ayam .! -_ h 4'7 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ..RECONDITION❑ DESTRUCTION_❑ - _ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER 1:1 'PUMP INSTALLATION® PUMP REPAIR❑ O/a <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field -Cesspool/Seepage Pit Other V" <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL } w - �.❑ CABLE TOOL Dia. of Well Excavation - - <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <br /> ❑ IRRIGATION ❑ GRAVEL PACK-} Depth of Grout Seal "� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY x..Y: Type of Grout <br /> ❑ DISPOSAL "❑OTHER - Other Information <br /> ❑ GEOPHYSICAL r: �'' Surface Seal Installed By: ? <br /> PUMP INSTALLATION: Contractor e 4, # <br /> Type of Pump <br /> PUMP REPLACEMENT:- - ❑ State Work Done .. - --" - <br /> PUMP s State Work Done � wIn <br /> DESTRUCTION OF WELL: W Well Diameter Approximate Depth - <br /> Describe Material and Procedure <br /> , <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joy <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 in the performance of the work for whit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws "Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of-the workspermit is issued, 1 shall employ persons subject to workman's compensation laws of California:" <br /> I will call for a Grout Insp-eccti ri 10 and a final inspection. pSigned +w Gtre x Date: 6 <br /> (Draw Plot PINh on Reverse Side) <br /> O FOR DEPARTMENT USE ONLY <br /> PHASE I `��,• ��,/��, <br /> Application Accepted By "'�"�-� "'' Date�y, <br /> Additional Comments: <br /> Phase II Grout Inspectionhese III Final Inspection <br /> Inspection By Date Inspection By 4Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE, <br /> T <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No.- Iss nce Date.- Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952131 <br />