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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appii cation. -� <br /> FOR OF„.EtCE USE:� APPLICATION <br /> ",,p IV (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL/`� � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE), O't7e? .�_ Cy'P�€�pA`T�R QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora /0-71 �o�-1,P, <br /> permit to construct and/or install the work herein described.This application is <br /> made in compliance wi h San Joaquin Co ty Ordinanc No.�1862 and the rules an reguIa i, San Joa um Local Health District, <br /> Exact Site Address i! o e CATV/town <br /> Owner's Name �m - S' i Phone <br /> Address Al. aJ city— <br /> Contractor's <br /> ity Contractor's Name Z'7'aO / A u.. License# IY3 77!�`Business Phone 74.74 <br /> Contractor's Address a0a? 04 A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fileith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11DEEPEN RECONDITIONS DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ F <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 WELLrt <br /> ElINDUSTRIAL 13CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE i F;; ❑ DRILLED Dia. of Well Casing ; <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i <br /> .IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal # <br /> E]' CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER �Other Information <br /> ❑ GEOPHYSICAL / Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractorc�7' m ;,o .� , <br /> Type of Pump c 'u„F��✓ _�il� H.P. G, <br /> PUMP REPLACEMENT: 13 State Work Done f <br /> PUMP RMIXIM R: State Work Done <br /> j <br /> DESTRUCTION OF WELL: 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 /> 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 which 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." t <br /> t <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performanceof the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection rio t rodfing nd a final inspection. <br /> Signed X e: Date: <br /> (Draw Plot P n on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI t <br /> Application Accepted By <br /> Additional Comments:— r <br /> Phase It Grout inspection Phase III Final Inspection <br /> Inspection By__r Date Inspection BDate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jffi'fuary 31 ❑ July 1 &Received By July 31 <br /> C <br /> BILLING REMITTANE $ REMIT i <br /> RASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT II <br /> FEE ; <br /> LESS <br /> PRORATION 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> 'SW <br /> Received by Date - Receipt No. Permit No. Issua cel— Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - , <br />