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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignThewppucauon. <br /> F <br /> APPLICATION <br /> FyR oFF°CE USE: <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> I - <br /> ENVIRONMENTAL HEALTH PERMIT <br /> "WATER QUALITY DS,3-� /(ed , Q <br /> r (COMPLETE IN TRIPLICATE) t'ITpZ.Gr _ _. GL�iLt IE/J1 --• n * f� <br /> Application is hereby made to the San Joaquin Local Health District fora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with Sp.Joaquin County Ordinance No. 1862 and the rules and regulations Of the San Joaquin Local Health District. <br /> �. p P + Mik bd [�,r clear en_cs /Yawn 1 <br /> Exact Site Address 11-- <br /> lAf. �1 1^�.D �� Phone , I'X80 <br /> Owner's Name OZ <br /> Address ,jJ ?AJr! _' }�. 1�r City. <br /> Contractor's Name t� License# Business Phone <br /> Contractor's Address Emergency Phone: <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes - No ./ <br /> TYPE OF WORK (CHECK): NEW,WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ hopc-0+ <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 07 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> X IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ' ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> El GEOPHYSICAL <br /> Surface Seat Installed By: <br /> PUMP INSTALLATION: Contractor irft <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: 4 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 /> Z <br /> 4 _ 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 whichthis 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:"1 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 wi caGf/i a Grout Inspection prior to grouting and a final inspection. p <br /> Signed X Title: RS�— Date: / <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �— <br /> Application Accepted B Date <br /> Additional Comments: <br /> Phase 11 Grout inspection III Final lnspection 6 <br /> Inspection By� — Date. - Inspection By Dale <br /> r <br /> d By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE C1EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveREMITuIy 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ➢ <br /> J. AD116 <br /> Received by Dat eceipt No. Permit No, I sua Delivered <br /> ce Date Mailed - <br /> N AVE.,P.O.6oti 2009 5TOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1607 E.HAZELTD <br />