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` Applications Will Be Processed When Submitted ProperlyComplete larei�o"ii ryngARp,Pca�ip�t; <br /> ..FOR OFFICE USE: APPLICATION ��►SIIIN <br /> (For Non-Transferable, Revocable, Sus le) AN 2 5 1980 [� <br /> .t o PUMP&WELL t�j <br /> ENVIRONMENTAL HEALTH PERMIT 12�- 190 <br /> WATER QUALITY S[,N -,vv '11�'N 5-Of ?NL �9 <br /> (COMPLETE IN TRIPLICATE) .7-rOOO ucJ- t4f�Mw�q�/ct a <br /> Application is hereby made to the San Joaquin Local Health Disrl tforapermittoconstructand/orit4tFa-AbX,�6r1�'�a`Jcrl c&lrribed.Thisapplicationis <br /> made in compliance w th San Joaq C unty Ordinance N . 1862 nd the rules nd regulations of the San Jo q i Local Health District. <br /> Exact Site Address� City/Town <br /> Owner's Name Phone <br /> Address City <br /> ZVContractor's Name nn� License# �f. Business Phone <br /> Contractor's Address X Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yeses No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 24 PUMP REPAIR <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank _ � Sewer Lines� � Pit Privy c <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line__-Ott Private Domestic Well Public Domestic Well ^— <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of.Well Excavation <br /> 13DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �� T <br /> 19 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION J9 GRAVEL PACK Depth of Grout Seal Cf S gea,: i°Alf <br /> ❑ CATHODIC PROTECTION JK ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ;�; Surface Seal Installed By: n <br /> PUMP INSTALLATION: Contractor / ��" <br /> Type of Pump H.P. •s- <br /> PUMP REPLACEMENT: ❑ State Work Done c, <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth k <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 /> N. <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <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 /> 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." <br /> I gWlll c r a G ut e-ctiioon^�prior to grouting and a final insp a lo a <br /> Signed X �� / l Title: / Date: _ / -23 <br /> (Draw Plot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date -/-� <br /> Additional Comments: <br /> Kyyao�ss�e�R Grout Inspection h se III Final Inspection <br /> Inspection By- �/C- Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Recewed 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 /> OTHER <br /> �-asap <br /> Received by Date Receipt No. Pe i Issuance Dale Mai#ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 20 <br /> ti� <br />