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f Applications Will Be Processed When Submitted Properly Completed! Be Sure To Sign TheApplicatlon. <br /> FOR OFFICE USE. I APPLICATION <br /> i (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WI=LL <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application its <br /> ` made in compliance with San Joaquin County rdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> 1 Exact Site Addres/s}� o d I' d City/Town -S <br /> Owner's Name I�L G! �►" y r r 5 Phone ��^Jqp <br /> Address 11Cn Lh er CityObl <br /> Contractor's NameAgp r. License#3�{�!�k 3 Business Phone 3 6 - 1679 <br /> Contractor's Address 006Wr Emergency Phone <br /> r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> ft <br /> TYPE OF WORK"(CHECK): NF'W WELLY , DEEPEN.❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLOFIINATION ❑ ~ WELL-ABANDONMENT❑ - OTHER ❑ PUMP 1NSTALLATIONt< PUMP REPAIR❑ C <br /> REPLACEMENT❑ If .� ^� <br /> DISTANGE TO�NEAREST'� S�ptic Tanker 'Sewer Lines Pit Privya�_� ,t _ <br /> Sewage Disposal Field 1=7 Cesspool/Seepage Pit &)C)t_; Other <br /> Property LinQPPrivate Domestic Well 10C2 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 9(OMESTIC/PRiVATE <br /> DUSTRIAL I I CABLE TOOL D(a. ofWell Excavation >' v ^'❑ DRILLED Dia. of�Well= sing <br /> ❑ DOMESTIC/PUBLIC ` ❑ DRIVEN Gauge of Casing CP G <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal`* t,wr'�- -- <br /> ❑ CATHODIC PROTECTION I <- .❑ ROTARY Type of Groutl C-4- <br /> `. ❑ DISPOSAL I ❑ OTHER Other Information + r "` <br /> ❑ GEOPHYSICAL {� 1 �CJ <br /> Surface Seal Installetl By:- <br /> PUMP INSTALLATION: i E Contractor 1� n 1 %11 _h <br /> I I ...Type bf Pump y m i1�[] v- _, Gc H.P. <br /> R PUMP REPLACEMENT: i ❑ State Work Done ..f ' <br /> PUMP REPAIR-' 0 State Work Done T <br /> DESTRUCTION OF WELL: I Well Diameter Approximate Depth C <br /> L <br /> f � Describe Material and Procedure � -- - <br /> I hereby certify that;l 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 Heal lth District. <br /> Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work forwhich this permit <br /> A reissued, I shall not iE mpioy any person in such manner as to become subject to workman's compensation laws of California." <br /> tJJ� C6ntractor's hiring oRsuh-contracting signature certifies the following:"f certify that in the performance of the work for which this <br /> pi�rrrit is issued, ) sh1a11 employ persons subject to workman's compensation laws of California." <br /> I plk <br /> tANIII call fora Grouf 1 ection prior to groulin and a final inspection. <br /> IF Signed X I Title: �1'� — Date: 1 119` ?�C� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date I�a <br /> Additional Comments: '�M' <br /> f Pis lGroultl9fpection _ �i P Itll Final I pection <br /> Inspection B /IV Date a Inspection By Date 46, <br /> Fee Is Due: ❑ ANNUALLY:1 i ❑ PER UNIT Ibl PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> IM <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANA l0N DATE' DATE REMITTED AMOUNT DUE AMOUNT <br /> JL <br /> r 9� <br /> I FEE <br /> LESS <br /> PRORATION I - <br /> PLUS <br /> PENALTY I { <br /> OTHER I� <br /> k II <br /> t OTHER <br /> Received by D'a'te - Receipt No. Permit No. Issuance Date .Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMITJSERVICES - 1601 E.HAZELTON'AYE.,P.O.Box-2009 STOGKTON,CA 95201 <br />