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r Applications Will Be Processed When Submitted Properly Completed.Be Sure ToSignTheApPlicarlon. it &Z.)`>- <br /> APPLICATION jJu � ,¢,f 7-�G?q <br /> FOR'OFFICE USE: L Y - <br /> (For Non-Transferable, Revocable,Suspendable) /l I PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT a-/'1 F <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY _ <br /> strict fora permit to construct and/oHnstall the work herein described,This application is <br /> Application is hereby made to the San Joaquin Local Health Di <br /> made in compliance with San Joaquin County Ordi`ance No. 1862 and t+e r les and lations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name ' <br /> � 45 <br /> City,. <br /> Address ..!!�� AA <br /> Licensubf_!! 4Z_ Business Phone <br /> Contractor's Name � <br /> Contractor's Address .5 �— Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL `DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT E] OTHER 1:1 PUMP INSTALLATIONI��PUMP REPAIR❑ <br /> REPLACEMENT❑ ^v f# <br /> DISTANCE TO NEAREST: Septic Tank <br /> sewer Lines T . JPit Privy s <br /> Sewage Disposal Fief J Cesspool/Seepage Pit j Other V <br /> Property Line-�Private Domestic Well Public Domestic We <br /> INTENDED USE TYPE OF WELL •� <br /> ❑ INDUSTRIAL 13CABLE TOOL Dia. of Well Excavation r <br /> i—DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> B-TflRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION RIMTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑,GEOPHYSICAL Surface Seal Installed By, <br /> PUR&INSTALLATION: Contractor <br /> } Type of Pump ' H.P. 00� le <br /> �© <br /> PUWP' REPLACEMENT: ❑ State Work Done <br /> PUMP' " REPAIR: C3State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure o <br /> y I hereby,certiiffy that"I have prepared this application and that the work will be done in accordance with San Joaquin County \ <br /> ordina�ns; fiich this permit <br /> cestate laws, grid rules and regulations of the San Joaquin Local Health Distract. <br /> Home'bwner,or licensed agent's signature certifies the following:"I certifythat in the performance of the work for w <br /> is is�ed, I shall not employ any person in such,manner as to become subject to workman's compensation laws of California," <br /> Contr'actor's.hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work for whit t Is <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will for a Grout Inspection prior to grouti a final inspection. <br /> ll;- � <br /> Signed X <br /> 7 Title: Date: <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPART NT USE ONLY <br /> PHASE 1 ; � � Dat a � 117 <br /> Application Accepted By <br /> Additional Comments: Pha I Final I ection +) <br /> Phase II Grout Inspection , f <br /> t;p. E inspection y Date <br /> �' Inspection By f � Date � ' B <br /> � <br /> f Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ J nuary'1 8�eceived By January 31 ❑ July'i &Receiv c By REMIT 31 <br /> f BILLING REMITTANCE t 'A s AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED s+ AMOUNT <br /> FEE O <br /> 7d+d �,B� <br /> LESS r � , <br /> PRORATION <br /> i <br /> PLUS <br /> I• PENALTY <br /> I <br /> OTHER <br /> OTHER <br /> 'Received by <br /> Date Receipt No. z Permit No. +issuance Date Mailed Delivered <br /> . TH PERM4TISEAYICES 1601 E.HAZELTON'AYE.,P.O:Bor 2009 -STOCKTON,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEAL95201 <br /> a <br />