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„ 0-1, Applications Will Be Processed-When Submitted Properly Completed. Be Sure To Sign The Application. } <br /> FOR OCE USE: 'APPLICATION y <br /> (For <br /> Non-Transferable, Revocable,,Sus endable <br /> ) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) qCY-r7 it/ _ GaTrA_8_), ,WATER QUALITY . t� Z-S— b�d ,. '' _ <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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. ..�. <br /> Exact Site Address /���d�Q �” 401fM f City/Town <br /> Owner's Name <br /> �lif`iG�� Phone . 3 4,9 7 <br /> Address C3 / City <br /> Contractor's Name License#/�a37_3 Business phone <br /> Contractor's Address6 :ZEmergency Phdne T 6_--5P <br /> Is Certificate of Workman's Compensation Insu ance on File With SJLHD? Yes Y No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑" RECONDITION❑ DESTRUCTION© " 4 <br /> r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0-'- PUMP REPAIR❑ <br /> REPLACEMENT D �y <br /> DISTANCE TO NEAREST: Septic Tank a4 Sewer Liries y2 Sb Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL r� <br /> ❑ fN USTRIAL ❑ CABLE TOOL .Dia. of Well Excavation T�pz <br /> Lg�DOMESTIC/PRIVATE El DRILLED r Dia. of Well Casing r2 <br /> ❑ DOMESTIC/PUBLIC i El DRIVEN Gauge of Ca Ing / <br /> ❑ IRRIGATION _ ❑ G VEL PACK ,, Depth of Gro Seal <br /> _,� , I <br /> ❑ CATHODIC PROTECTION L�ROTARY f 1 Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 'Other Information 4 <br /> ❑ GEOPHYSICAL surface Seal Installed y:'^ <br /> PUMP INSTALLATION: i Contractor <br /> Type.of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: I] State Work Done , . <br /> DESTRUCTION OF WELL: Well Diameter :! Approximate Depth V <br /> Describe Material and Procedure - <br /> I J <br /> 5 <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 /> Home owner 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." } <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi 11 for Grout I r tion prior to grouting and <br /> ��a��final inspec ion. i " <br /> Signed X I /-Title: Date: 1I <br /> (Draw Plot Plan on Reverse idd) <br /> tAl_ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE � 1 <br /> � _ <br /> Application Accepted By�/__� .�. �• Date a �`� <br /> Additional Comments: <br /> Phase II grout Inspection 4' a 11 Final nspection <br /> In`spection By`— ate��� V�� �" -Inspection By 'D to <br /> Fee IS Due: 13 ANNUALLY '[].PER UNIT 13 PER SITE ❑ EACH ❑ January 1 &Recei By January 31 El July 1 &Received By July 31 <br /> k I BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE' REMITTED" AMOUNT <br /> k , t <br /> FEE �P�p <br /> LESS <br /> a PRORATION _; !` <br /> PLUS <br /> -w, PENALTY + i <br /> OTHER <br /> 't! <br /> .,%^"OTHER <br /> 'eceivetl by ti Date Receipt No. Perini[No. Issuance ate Mailed Dekivered j <br /> " /APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ <br />