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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ` <br /> FoJIRWJCE USE: APPLICATION] <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY N <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install theworkherein described.This applicationis 6 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. o <br /> Exact Site Address Wi 7 04 Argyl l= f //S r �. c� L City/Town Is ;reel/f%0 Al <br /> Owner's Name , .� -'/" I//C1' /?9r,4 ire! Phone ''A.6Z - <br /> Address 3- Y-7 M, -22272 L, 11- City / UGIf-7'G <br /> Contractor's NameG-'49R/& IA46-1 , Ce M14.License#37/U L6 Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION K <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 /> ❑ 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> �I gall ora .rout Inspections'prior to grouting and a final inspection. > �j <br /> Signed X5 1� ,�` /"J fzv�f Title: 6 - Date: La <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPART ENT USE ONLY <br /> PHASE I 7c <br /> Application Accepted By 13— Date d� / <br /> Additional Comments: <br /> ha it ut Inspection i Phase 111 Final Inspection <br /> Inspection By Date I, ( 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS \ 4 <br /> PENALTY } , <br /> 143 <br /> OTHER <br /> E <br /> OTHER <br /> Ca <br /> �9—IZ�o1r� i a�-71 <br /> Received by Date Receipt No. Permit No. Is uance Dam Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />