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_ .Apjifications Will Be�Prdcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br />fF �¢FrICEusE: � Y b�For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL <br /> - <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WA pER QUALITY -7dr-7 N _ <br /> Application is hereby made to the San Joaquin Local Health District fora ermittoconstruct a d rinsallthework erelndesclbed.Thisa licationis <br /> made in compliance wit San Joaquin County Ordinance No..1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Ch at, pl � {� /—>_,_ iTT�� City/Town �/ } <br /> Phone -3 �� i fe3 <br /> Owner's Name [tp i <br /> Address � � Lon City <br /> Contractor's Name _J�Soac E� pct �(}' License#_�35 �3 Business Phone F�1�—�sf/ 7 <br /> Contractor's Address Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No y a <br /> TYPE OF WORK (CHECK): NEW WELL 0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ <br /> REPLACEMENT11 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 4 �— Private Domestic Well Public Domestic Well <br /> _ INTENDED USE TYPE OF WELL / r <br /> ❑ INDUSTRIAL El CABLE TOOL Dia. of Well Excavation & if <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IFIRIGATION ❑ GRAVEL PACK Depth of Grout Seal �a <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ 'OTHER Other Information <br /> d <br /> ❑ GEOPHYSICAL Surface Seal Installed By: e- <br /> T <br /> PUMP INSTALLATION: Contractor <br /> Type ofyPump Su . U H.P. <br /> PUMP REPLACEMENT: ❑ StateWork Done ,." <br /> PUMP REPAIR: ❑ State Work Done - <br /> v APo <br /> DESTRUCTION OF WELL: Well Diameter ximate Depth o !{ <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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California T H <br /> I will c for-a Grout Ins 'on rior tofinal irispectiori` <br /> Signed X Title., - Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT USE ONLY <br /> PHASE 1 ,' <br /> Application Accepted By Date <br /> Additional Comments: r` <br /> Phase,II Grout inspect n 7 4ha 141 Final inspection <br /> Inspection By ate / '� Inspection By ate a a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January ❑ July-1 &Received By Jury 31 <br /> REMIT <br /> KILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EASE EXPLANATION DATE DATE REMITTED r <br /> AMOUNT <br /> FEE L_ <br /> LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY f <br /> OTHER <br /> OTHER rt <br /> "`Dates Receipt No. Permit No. r -F Issuance We Mailed - Delivered <br /> Recetvetl by - <br /> ON AVE.,P.O.Boy 2409 STOCKTON <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELT ,CA 9' " <br /> -_�� i <br />