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—.ter �1jr , AM ucauun. <br /> Appplili cations Will Be Processed When Submitted Properly Completed.Be Sure oSign <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable;Su spendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> WATER QUALITY . -mi ►3 <br /> (COMPLETE IN TRIPLICATE) <br /> Local Health District for a permit to construct and/or install thework herein described.This application Is <br /> Application is hereby madeto theSan Joaquin <br /> made in compliance with San Joaquin Count Ordinance No..1862 an a rules and r ulations of the San Joaquin L��Health District. <br /> r{ 1 p ' � City/Town <br /> Exact Site Address <br /> G A�� Phone 6 <br /> F Owner's Name City 1 <br /> i Address $f IJ LOsI N�h—/D�P //►�l ��{� <br /> GO_v� k License#7"7717 Business Phone ZS <br /> Contractor's Name +`" <br /> Contractor's Address �Yr7� >7 : Emergency <br /> Phone <br /> l_VGC <br /> I No <br /> Is Certificate of Workman's Gompertsation Insurance on File With SJLHD? Yes R <br /> TYPE OF WORK (CHECK): NEW WELD r DEEPEN ❑ RECON❑DITI PUMP INSTALLAT ONO PUMP REPAIR❑ <br /> WELL CHLORINATION C1 WELL ABANDONMENT ❑ OTHER <br /> REPLACEMENT❑ II, Sewer Lines Pit Privy y <br /> k DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sews ge Disposal Field <br /> Property Line Private Domestic Weil Public Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE <br /> 13 INDUSTRIAL I 13 CABLE TOOL Dia. of Wel! Excavation f <br /> 11 DRILLED Dia. of Well Casing �C <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11 IRRIGATION GRAVEL PACK Depth of Grout SI <br /> ROTARY Type of Grout f <br /> 11 CATHODIC PROTECTION i� X Other Information <br /> ❑ DISPOSAL I ❑ OTHER <br /> Surface Seal installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: ' Contractor <br /> Type of Pump L v' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> 13 state Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <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 agent's signature certities the following:"I certify that inthe performance of the work forwhich this permit <br /> manner t to workman's compensation laws of California." <br /> is issued, I shall not employ any person in such as to become subjec <br /> Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation}laws of California." <br /> i <br /> I will call for a Grout!inspection prior to grouting-and a final.inspection.. <br /> I I Title. C �/Vl � Dale: 1 <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r ��! Date <br /> Application Accepted By <br /> Lh <br /> Additional Comments: �I <br /> base 11 Grout ection <br /> Inspection By Phase III Final Inspection <br /> - Date Inspection By Date <br /> Fee Is DUe: ElANNUALLYI1 []'PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &ReceivedREMIT <br /> uiy 91 <br /> Ir I . BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> II 4t B <br /> �g I <br /> FEE <br /> LESS ��� <br /> PRORATION II <br /> PLUS <br /> PENALTY !I <br /> i <br /> OTHER I� <br /> { <br /> OTHER <br /> 4� 0 <br /> Pi[No.Y` Issuance Date Mailed Delivered <br /> Received by' ate• Receipt No. Permit <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20139 STOCKTON,CA 95201 <br />