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li6a4io"6VAI aFgoc"�en Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USELS APPLICATION <br /> SEP 6 1979 (Fpr on-Transferable, Revocable, Suspendable) <br /> PUMP&WEI.1, <br /> AN �p/�, �fN ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLIC41EAL rH T�R��'gL WATER QUALM y <br /> DTUri 'b TT a(7`�`g'7 fs' �scskto 0 Ec�r�i 4 ."". `�nJ.. 2-2-S—oc� <br /> Application is hereby madetotheSanJoaqu L Itis Ithplstrictorapermlttoconsructand/orinstall'thework herein described.This application i5 <br /> made in compliance with San Joaquin//County Ordinance N .1862 and the rul s an+d/regula�'o�ns f t e San aquin Local}�ealth District. ° <br /> Exact Site Address o�C3e 11�• V �/ i► yfa� ��►31r.1' Ox. Jsec?la19•,[ ��� n / <br /> Owner's Name /•I�a♦*t Phone3�� <br /> Address City qq r�r <br /> Contractor's Name ` IJ Q O License#� - o2aC0 <br /> qq n n �QLI� Business Phone <br /> Contractor's Address 0 atm 3 MQ i a 3 t- Emergency Phone SQ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes AU6 No t., ' <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 19 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 X 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 ~} y <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface S al In alled By: <br /> PUMP INSTALLATION: Contractor Mn dglrl <br /> Type of Pump 1�3ei_�y _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done r <br /> PUMP REPAIR: ❑ State Work Done _ V+ <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. i <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit m_ <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." r <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 employ persons subject to workman's compensation laws of California," R <br /> I wl all for Grout I pection prior to grouting and a final inspecti ['� j �J <br /> Signed X Title,. Date: 7--4J <br /> (Draw Plot Plan on'He erse Side) <br /> F R D ARTM7TPSE ONLY <br /> f <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pha FinIlectioInspection By Date Inspection ByaFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE. ❑ EACH ❑ January 1 &Received By January 31uly 1 &Received By July 31 <br /> REMIT <br /> $ 1 <br /> BASE EXPLANATION BILLING REMITTANCE DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEEv / t <br /> S <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE::P.O.Box 2009 STOCKTON,CA 95201 <br />