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Applications Will Be Processed When Sub fitted Properly Complete S n heV4p at <br /> FQ#-o E,` ,.USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable)Hf R S <br /> 198Q PUMP&WELL <br /> ENVIRONMENTAL HEALTH PER '� <br /> WATER QUALITYHEALTH <br /> Jt q,�11i LOQ <br /> (COMPLETE IN TRIPLICATE) H�,1�LT jjcc ,�(_ <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the wP4a-JQA3JrSCribed.This application is <br /> k made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local /Health District. <br /> c Exact Site Address �p/�5/ &,k 0 40V _S� � ._.__ City/Town lestses/ <br /> Owner's Name /� ���'{, Lla l%Jt6. Phone 93 <br /> Address _ � $ �' .����� City E' -sc-ea.lry 4/ <br /> Contractor's Name All-'-S License# }cam Business Phone <br /> Contractor's Address Aa"64,li( 7n_— T/eti1 C.i¢, Emergency Phone b",ef_-3 A" <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C3 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION I] WELL ABANDONMENT ElOTHER ❑ PUMP INSTALLATION 11PUMP REPAIR❑ <br /> REPLACEMENTO fhpti <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 ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 25 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> f ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> s ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: f i <br /> PUMP INSTALLATION: Contractor Alli ii Z7-,- h, <br /> Type of Pump -v O H.P. <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 /> 'r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i 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 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's cgmpensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> 01 <br /> Signed X Title: Date: .4-7-Ra <br /> (Draw Plot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY <br /> 4 PHASEI , <br /> Application Accepted By Date <br /> It Additional Comments: <br /> a Phase II Grout Inspection Phase ill Final Insp <br /> Inspection By Date Inspection By f~ <br /> I <br /> - Fee Is Due: ❑ ANNUALLY ❑ PER UNIT N7 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By.July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> - BAS EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> + :AMOUNT <br /> FEE e--- <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> �'- OTHER yJ <br /> e - <br /> �� L 6 <br /> Received by., Date Receipt No Permit No. I5 uane Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES X1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />