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Applicationsi Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> FOR OFFICE USE: !I <br /> (For Non-Transferable, Revocable, Suspendable) pUMP&WELL C <br /> ENVIRONMENTAL HEALTH PERMIT �r <br /> (COMPLETE IN TRIPLICATE) i' <br /> WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/orinstakltheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Heal h District. <br /> f <br /> Exact Site AddressX "�`" ' '� f City/Town _!��fctr��TT�c +1C Pewr!K.rs <br /> I. C-r^clQnv <br /> Owner's Name �A7V�tf� Phone <br /> S d / t y"p lam. , C 9 7 City #R+¢.r1 1 cfi "I t R <br /> Address —�—� r <br /> Contractor's Name <br /> yiJ j License# � � ='� Business hone_ <br /> ATI d Emergency/1�, �;.� ency Phone <br /> Contractor's Address 2-t.5- /�'+ � g <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes X No <br /> TYPE OF WORK {CHECK): NE=1 WELL❑ DEEPEN 11 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT.❑ OTHER ❑_"WPUMP INSTALLATION ® PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy - <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> a <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE ` TYPE OF WELL <br /> ❑ INDUSTRIAL II ❑ CABLE TOOL _ r� _Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE N ❑ DRILLED w Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -V <br /> ❑ <br /> 19 IRRIGATION GRAVEL PACK Depth of Grout Seal W <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> II <br /> ❑ DISPOSAL 1 ❑'OTHER. '= Other Informatidn_ �+ <br /> El GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump !•t);'f�«lC H.P. <br /> PUMP REPLACEMENT: I� El State Work Done <br /> PUMP REPAIR: 13 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> I " <br /> i <br /> I hereby certify that til 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 license d agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 <br /> I will call for a Grout lInspection prior to grouting and a final inspection. <br /> ecs <br /> < �/ �, � %W1rS Date: <br /> Signed X r � fC/ �'""� Titley <br /> (Draw Plot Plan on Reverse Side) <br /> x <br /> Ik FOR EPARTM NT USE ONLY <br /> PHASE I <br /> J Date <br /> Application Accepted Bylk <br /> Additional Comments: <br /> 9 Phase 111 Final Inspection <br /> Phase 11 Grout Inspection <br /> } <br /> Inspection By 11 Date Inspection By Date <br /> if <br /> Fee Is Due: El ANNUALLY" ❑ PER UNIT ❑ PER SITE El ❑ January 1 &Received By January 31 El July 1 &ReceivREMITBy uly 31 <br /> Ii BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED. AMOUNT <br /> FEE _ -- <br /> LESS II <br /> PRORATION I <br /> ,6 <br /> PLUS <br /> PENALTY I <br /> OTHER <br /> OTHER I� <br /> C�_ 3- <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box2009 STOCKTONCA 9520 <br />