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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&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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_ - /77d rte_ Z10 City/Town L-11;-40e_1J <br /> Owner's Name I`Y.- ��mCd Do .SaiV �Z/IJG. Phone '?3/ -7S4 F <br /> Address _ 6`°7 7 /U -741) 1/ City <br /> Contractor's Name /?-);i, Li J License# 34,06'S-1 Business Phone ��-7— a39 5� <br /> I Contractor's Address eW Pee-6 �i -- .,o.41<_ 9-/e_ Emergency Phone 5lt-rr1. 4 5 6u <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 01 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑s OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> i l <br /> DISTANCE TO NEAREST: Septic Tank _S-Ot Sewer Lines � � Pit Privy Md <br /> Sewage Disposal Field e"Vf*% e . Cesspool/Seepage PitS Gd Other "Vo -ii <br /> Property Lined Private Domestic Well Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> L DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> k ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12- <br /> IRRIGATION <br /> ZIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal .20 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CN'T Cr <br /> ❑ DISPOSAL ❑ OTHER Other Information -7-4 0!0 <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: /n P S • =eu,G <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump H.P. <br /> I' PUMP REPLACEMENT: ❑ State Work Done H <br /> PUMP REPAIR: ❑ State Work Done <br /> { DESTRUCTION OF WELL: Well Diameter A <br /> pproximate Depth <br /> r Describe Material and Procedure }t <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 thework forwhich 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 shall a loy persons subject to workman's compensation laws of California." " (T <br /> I will call for ou ns cti n prior to grouting and a final inspection. <br /> Title: <br /> Date: <br /> �f b ��a <br /> I (Draw Piot Plan on Reverse Side) <br /> r FORD PAR ENT US ONLY l <br /> t. PHASE 1 � r7� <br /> } Application Accepted By. Date / d! <br /> Additional Comments: <br /> I Grout Inspectio� Phase III Final Inspection <br /> Inspection By Pha P tiDate.— � " Inspection By Date <br /> El 1 &Received By Ja uary 31 Juky 1 Received By July 31 <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT WIPER SITE El EACH , <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �{ <br /> F <br /> M LESS <br /> �e PRORATION <br /> PLUS <br /> j = PENALTY �p <br /> F€b OTHER i <br /> T OTHER_ <br /> h � <br /> Received by' Date Receipt No. Permit No. Issuance Date Mailed Delivered { <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2004 STOCKTON,CA 95201 <br />