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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) p l r-445_-,C{ G.f*�C�, TER QUALITY ;2-<) (�cP�—I C. <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`J�aquin al Health District. <br /> Exact Site Address M%voi.0 b� I"iv D- k C _W Q City/Town <br /> Owner's Name 4Ta~A AL G1 01F taw Phone RL — 62S' <br /> Address ��� 1={�E'1►�'�`MI? City y1s <br /> Contractor's Name +G VV e,SANMp6nLicense# Business Phone <br /> Contractor's Address-%0iI11AS VIVII-f . Emergency Phone !� <br /> -Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes LP-00 No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 /> E] INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation 210\ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC El DRIVEN I Gauge of Casing t'�� f <br /> CIO <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ESI"L10 <br /> ❑ CATHODIC PROTECTION ❑ ROTVY r Type.of Grout <br /> ❑ DISPOSAL ❑ OTHERa OAher information <br /> Suffay: <br /> cdrSeal Installed B �Sl <br /> ❑ GEOPHYSICAL * i <br /> PUMP INSTALLATION: Contractor �� + <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done M <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this app 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the ptirformance of theworkifor 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 /> tractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> it is iss e I shall emplo person subject to workman's compensation laws of California." <br /> I call for G o t Ins ii prior t grouting and a final inspection. <br /> IC <br /> 1 � <br /> Signed X Title: Atz-- U"" ` W C F_ ate: W. �Z <br /> (Draw Plot Plan on Reverse Side) <br /> 5 <br /> FOR DEPARTMENT USE ONLY <br /> ( <br /> PHASE I � <br /> Application Accepted By Date �/z <br /> Additional Comments: <br /> Phase II Grout Inspection ,L- Phase III Final In pection <br /> —Inspection-By— _.Date. >�` ��� lnspscti.on..l3w <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER 517E EACH ❑ January 1 &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 Q <br /> LESS <br /> PRORATION ++ I <br /> PLUS Z <br /> PENALTY l_Le- YA- <br /> OTHER flevvylclV <br /> v I )"' Orfrt L,GIf 4id} �lveldled jf lrk r fT fCL <br /> OTHER <br /> 4 1 aI We/ <br /> Received by Date Receipt No. Permit No. ssua a Date 1 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />