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•f_. _� -�.—s�-�=�--�.�-tip-. —:-�'..,,-.�. ..�:. -. ... - '-r.. — - <br /> Applications Will Be Processed When Submftle'd. Properly <br /> � t� ei �a <br /> FOR OFFljPr.USE., APPLICATIQN <br /> (For Non-Transferable, Revocable, S da <br /> W1 �gg� <br /> At PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> `,vIN LMAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY: SI�.NTr 4 I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to con structand/�"IPt4,wT t]escribed.Thisapplicationis 'l <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San JoaquinLocal Health Distr�cZ. <br /> Ex' site Address 733 Dudley Road city/Town Feench Camp, Carif. 95231 <br /> Owner's Name :Chester MeekPhone 982-1197 <br /> Address 733Dudle Road ' City French Camp, Calit. <br /> Contractor's Name Noack Pump License# 355213 Business Phone 948-8817 <br /> 94 ;-8817 <br /> Contractor's Address 00 EFrem p Emergency Phone <br /> 9 ic)&t.IT— _L - <br /> Is Certificate of Workman's Gompensa�ion Insurance on File With SJLHD? Yes No , r I <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION D DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION78 PUMP REPAIR❑ <br /> REPLACEMENT❑ ` <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 WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ 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: Contractor Noack Pum <br /> Type of Pump Submersible H.P. 1 � <br /> PUMP REPLACEMENT: "❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 /> t <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." <br /> I 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 I wilt call fo a Grout Ins coon prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> r _ FOR DEPARTME14Y USE ONLY <br /> PHASE I M <br /> Application Accepted By Date ~ <br /> Additional Comrnent_: N. <br /> 4 <br /> Phase 11 Grout Inspection P III Fin <br /> Inspection By Date Inspection S <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Janua &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE "EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> v <br /> OTHER <br /> i o <br /> Received by Date Receipt No. Permit No rssuancqDald Mailed Delivered - <br />�. <br /> APPL-IGANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON-AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />