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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: /�� APPLICATION.[ (For Non-Transferable, Revocable, Suspendable) <br /> - •_ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY r 4 <br /> (COMPLETE IN TRIPLICATE) c�fj f Z„ C ID�0 G7 _ /71— z "' <br /> App Iication isherebymade tothe San JoaquinLocal Heal thDistrict foraperm ittoconstruct and/orinstaIItheworkere indescribed.Thisapp Iicationis�,. <br /> made in compliance with San Joaquin County 0 di ance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site AddressCQ!yip 1'__ a Ko-� cu d�- o- 41 �.�raw1"a W City/Town <br /> Owner's Name � � �` H G� Phone <br /> Address q 1.6 A� _ — —. City "a. <br /> Contractor's Name License#/23 72 1 Business Phone jo -7 <br /> Contractor's Address 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 ❑ OTHER ❑ PUMP INSTALLATION 99 PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> t <br /> y <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy f , <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �u <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation tin r <br /> 4 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ,{ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Y ) <br /> ❑ CATHODIC.PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Inst By: <br /> PUMP INSTALLATION: Contractor . y <br /> Type of Pump H.P. <br /> �^ <br /> PUMP REPLACEMENT: ,9 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> c - <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 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." <br /> I will call for a Grout Insp tl p fort utmg and final inspection. <br /> Signed X - _itle: iS*"_ P Date: r <br /> (Draw PI Ian on Reverse Side) H <br /> R DEPARTMENT USE ONLY ` <br /> PHASE I <br /> Application Acceptedy Date�� <br /> Additional Comments: I <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection By 464e,4'_ Date Inspection By Date <br /> j <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 4 <br /> V REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION OATS D TE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt-No. Permit No. Issue ce D e Mailed Delivered , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOC ON:'[: 52 1 .k <br />