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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> endable) <br /> (For Non-Transferable, Revocable, Susp <br /> �- PUMP&wEl_I, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and t e rules and regulations of the San Joaq n Local Health District. <br /> o <br /> Exact Site Address �� � G P �5� City/Town <br /> Owner's Name L Phone 01 <br /> Address /3?yiL-IP City <br /> Contractor's Name%� v A License#3rnb� S/ Business Phone I <br /> Contractor's Address �C' �� Emergency Phone q — 0 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes t--- No <br /> TYPE OF WORK (CHECK): NEW WELLP--- DEEPEN ❑ RECONDITION❑ DESTRUCTION 11 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> l DISTANCE TO NEAREST: Septic Tank _465 Se7er Lines _ � y`�^ Pit Privy <br /> Sewage Disposal Field_ .fid "� Cesspool/Seepage Pit _ Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL !/ <br /> ❑,, INSTRIAL 1:1 CABLE TOOL Dia. of Well Excavation <br /> il"DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 13 GP PACK Depth of Grout Seal �� t <br /> ❑ CATHODIC PROTECTION 2-ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: /1• . -+ Ar< (X <br /> PUMP INSTALLATION: Contractor 'J <br /> Type of Pump H.P. <br /> I 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 1 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 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 sh a Io s subject to workman's compensation laws of California." <br /> Ill call for a Grout ns n for t routing and a final inspection. <br /> f <br /> Signed .Title: n r Date: <br /> Draw Plot Plan on Reverse Side) <br /> r <br /> } FOR DEPARTMENT USE ONLY _ <br /> 4 PHASE 1 G`(�1 "�1'urS�P{ tq1$ p <br /> Application Accepted By 1 t 1 3 — )VILL Date <br /> Additional Comments: <br /> f <br /> PIMse 11 Grout Inspection Phase III Final Inspection <br /> Insp ction By Date ` 3 �8o Inspection By Date <br /> 1`1cs�reodyf � lave- De�M I�S5/��t )r`o <br /> Fee Is Due:] ANfQUALLY 1 ❑ PER UNIT ❑ PER ITE ❑ EACH ❑ January l &Received By January 31 I❑ July 1 &Received-By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE- REMITTED AMOUNT <br /> FEES L4,5 <br /> to 143 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> c <br /> Received by ate Receipt No. Permit No. ,Issuance Date Mailed Delivered " <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.D.Box 2009 STOCKTON,CA 95201 <br />