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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: .APPLICATION . i <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WEL[. � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) )MTERQUALITY � ,j4 <br /> ,[_+��,� . �_ C-"D�tSTt�C- <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 0 <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. j <br /> Exact Site Address X P L * 5/` /.�1�/�ka,f 7 1,4 City/Town 4-14 � r �I 1 <br /> Owner's Name L� �fr PGrC P �C�/ _ Phone <br /> Address R077,fl, 71, IM City <br /> Contractor's Name�v �/ .5 License#� e) Business Phone <br /> Contractor's AddressR�_.o �s�iZ Zi 4 &Re, �s'GEmergency Phone �d7 <br /> i Is Certificate of Workman's Compensation Insurance on FilerSJLHD? Yes !� -- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN © RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT L1 OTHER 1:1 PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT l <br /> f=. DISTANCE TO NEAREST: Septic Tank 7-00 Sewer Lines Pit Privy <br />! Sewage Dilsposal Field Cesspool/Seepage Pit Other <br /> Property Lrine Private Domestic Well Public Domestic Well <br /> i INTENDED USE TYPE OF WELL a�1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation a m� <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> ❑IOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> RRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ~ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractort�� <br /> Type of Pump `f3Y /ir H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done — T <br /> PUMP REPAIR: ❑ State Work Done <br /> ti ✓ � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Thereby 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 rakes and regulations of the San Joaquin Local Health District. t <br /> dome owner or licensed agents signature certitie_"s the following[certify that-in the performance of thework forwhii6h 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 s employ persons subject to workman's compensation laws of California." <br /> } <br /> i I will all fora inspectiII on priorto using and a sinal inspection. <br /> i. Signed I Title: Date: <br /> (Draw Plot Plan on ReveKse Side) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Gro` ut Inspection Ph a III Inal I�n�spee on <br /> inspection By A3 � �IFL DWV — ate Inspection By� "'� Elate Z % <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ ; REMIT <br /> BASE .� EXPLANATION CHECKED <br /> DATE DATE REMITTED AMOUNT DUET t AMOUNT <br /> FEE <br /> LESS <br /> i PRORATION <br /> F PLUS <br /> PENALTY `[ <br /> OTHER 1 <br /> OTHER <br /> R - . <br /> 5 6 Y6 <br /> Received by Dater Receipt No. Permit No. Issuance Date - -Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.IiAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br />