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ApplicationsWill Be Processed When Submlited Properly Completed.-BeSure To Sign The Application. <br /> FOR DFFIC'USE: I� <br /> APPLICATION <br /> f (For Non-Transferable, Revocable;5uspendable) <br /> !� PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I; WATER QUALITY <br /> Application is hereby made <br /> 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 Joaqluin County Ordinance No. 1862 and the rules and regulations <br /> Exact Site Address 099111 E. CQ e-r0of is R of the San Joaquin Local Health District. <br /> 1 <br /> 0 City/Town Atn <br /> Owner's Name - Wil-11am Woods <br /> Address Phone <br /> Contractor's Name OOI mdI2 r Ott? City <br /> Contractor's Address icense#.2L-7_6_qfL__ Business Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHDv erges'y phone <br /> TYPE OF WORK (CHECK): NEV WELL DEEPEN ❑ Yees No <br /> WELL CHLORINATION 11 WE 13DESTRUCTION❑ - <br /> WEhLL ABANDONMENT 11REPLACEMENT❑ OTHER 13" PUMP INSTALLATIO40 PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: } Septic Tank <br /> Sewer Lines r' Pit Privy �1 <br /> + sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line_ private Domestic Well Other <br /> INTENDED USE Public Domestic Well <br /> ❑ IDUSTRIAL TYPE OF WELL <br /> j� + ❑ CABLE TOOL <br /> DOMESTIC/PRIVATE Dia. of Well Exc% avation �Z♦�GZ <br /> UHILLED Dia. of Well Casing t!/�G <br /> ❑ DOMESTIC/PUBLIC s Dia. <br /> ❑ IRRIGATION ❑ Gauge of Casing © l/e_ I <br /> ❑ CATHODIC PROTECTION �AVEL PACK Depth of Grout Seal <br /> ❑ DISPOSAL I ROTARY Type of Grout �. <br /> } I ❑ OTHER <br /> ❑ -GEOPHYSICAL i Other Information <br /> PUMP INSTALLATION: Surface Contractor Moorman Is Water Seal Installed B <br /> I Type of Pump_ st7}"tTriere; <br /> PUMP REPLACEMENT: �� ❑ State Work Done H.P. <br /> PUMP REPAIR: t <br /> DESTRUCTION OF WELL: � _ El State Work Done ` <br /> well,Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby certify that I have M <br /> prepared this application and that the work will be done in accordance with San"this'permit <br /> y <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 tis issued, I shall not employ any person in such manner as to become subject to workman's compensation la "Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the ws <br /> per is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed )( _ IC <br /> Title: <br /> (Draw Plot Plan on Reverse Side) Date: <br /> ;II FOR DEPARTMENT USE ONLY <br /> PHASE I ISI <br /> r <br /> Application Accepted B5111' / <br /> Additional Comments: I� Date <br /> r,Phase 11 G o't Inspection <br /> Inspection By i! Date _;Lb-eJ P se III Fina! Inspection <br /> IiI Inspection ByDate 4?--3 <br /> 3 <br /> Fee Is Due: ❑ ANNUALLY � ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jan ' <br /> uary 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> `� DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE x AMOUNT ' <br /> LESS LJ a <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER . <br /> OTHER I <br /> I <br /> I� <br /> --yea try• Date +�I Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: �i ENVIRONMENTAL HEALTH PERMITPSERVICESermit Noy Issu nce Dat Mailed <br /> Delivered <br /> 11 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />