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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. + <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) i <br /> ` PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 5 7'" ✓ <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is - <br /> made in compliance with San Joaquin County Ordinance No. 1 62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address xt 46 7L * /3 City/Town 5T0ck'0 Y1 <br /> S 8 S 3 cervi <br /> Yt? 7 �3)— <br /> .' <br /> Owner's Name PS _Q.Y Phone <br /> Address `6 0-N W d d r,lk City STOCL A!°To V1 <br /> Contractor's Name License# 33S"g/ 3 Business Phone <br /> Contractor's Address O O E :7 Y4h^014 Emergency Phone '?V g�- 84�-7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No <br /> TYPE OF WORK (CHECK): NEW WELL 0 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 StDD� Other <br /> Property Line ';40 1 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL !� 0 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing to { <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5o <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout {' <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: r o`A-C it Al 12W +� <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump S U, <br /> PUMP REPLACEMENT: ❑ State Work Done !;,7 N 5+-Iava PLA vyl <br /> PUMP REPAIR: ❑ State Work Done <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. <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 y� <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." !� <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X 1yl Title: (,;I Date: a 1 <br /> (Draw Plot Plan on Reverse Sig) <br /> FOR DEP RT <br /> MENT USE ONLY <br /> PHASE 9 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase IIr ut Inspection �7q Phase III Final Inspection / <br /> Inspection By �rrYlN�; 0 A(4�Date j�v� - / 1 Inspection By-;-"-`, Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ 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 Rao <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> - Lie <br /> `-7�t—13� S 1�9C 7S <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.O.Box 2009 STOCKTON,CA 95201 <br />