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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application, <br /> FOR OFFICE USE: APrPLICATION <br /> (For Non-Transferable,'Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_ 80 4 City/Town �tOCk't ATL. <br /> - #�s -. Phone 462- <br /> 9234 <br /> Owner's Name <br /> Address '"L.,_ f, �. r " _ City <br /> Contractor's Name ' i Pit P n t License#X1,56_0 'Business Phone 462-5597 <br /> rs ', `Emergency Phone: <br /> Contractor's Address ", I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 6 <br /> TYPE OF WORK (CHECK): NEW WELI'Q DEEPEN 11RECONDITION-❑ DESTRUCTION❑ -'- <br /> WELL CHLORINATION ❑• WELL ABANDONMENT ❑ OTHER R PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST:' Septic Tank 4' Sewer Liries ±50t� 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 /> Q DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing rl�vv� <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Kn t <br /> CATHODIC PROTECTION a ROTARY Type of Grout R gE� - - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Y <br /> ❑ GEOPHYSICAL. Surface Seal Installed By: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: ❑ State Work Done ,�h <br /> PUMP REPAIR: 10 State Work Done �X <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 forwhich this <br /> permit is issued, all e p y rsons ubject to workman's compensation laws of California." <br /> 1 w, Ifo ro In C11 n r gr ting and a final inspection. <br /> Signed X Title: 1rP Cl @-rk 14P-1 1 Date: Q Sept. 1982 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY y <br /> PHASE I (;4� � <br /> Application Accepted By w�"�� �� Date <br /> Additional Comments: <br /> ,—Phase 11 Grou Inspection Phase II Final Inspection , <br /> Inspection By Date 7 r3 yZ Inspection By i Date <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER LJWT ❑ PER SITE ' ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 00 <br /> SEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> ered <br /> Received by - Date - - Receipt No. - Permit No .r lssuan a Date Mailed PefC <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOKTON,GA 95201 <br />