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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) PUMP&WELL 2 vo <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 Joaquin Local Health District. <br /> Exact Site Address (� �� ,� �ji C' City/Town -51-e f i a N, C- et , <br /> pfpt elf ccrFecT�sr2 <br /> Owner's Name Wo�-YA&rw Cd,e . 16&wn a 4 Tr Phone <br /> Address -5"C70 n-. amtp <br /> -"00 2 Akc& R? l city <br /> Contractor's Name/9RvM,F-DiPVol 12kA l;y'd ri o&icense#74 l p Business Phone jr 21?q"9'9"A dl;-3417 <br /> Contractor's Address 2-6Z V� :� "' Emergency Phone <br /> Is Certificate of Workman's Compensation I su ncceo Fi I SJLHD? Yes I-- No <br /> TYPE OF WORK (CHECK): NEW WELL 0?00' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION M--' PUMP REPAIR.❑ <br /> REPLACEMENT❑ Ai eq.r,eST 57Cv__Pr l_;Al f /fpkvx 3,$-0 , <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit i Other <br /> Property Line Private Domestic Well Public Domestic Well A O d <br /> INTENDED USE TYPE OF WELL , <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r❑��DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> yr uOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION M-RGRAVEL PACK Depth of Grout Seal <br /> *�Gr <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CC <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ti 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 for which this <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. I <br /> Signed X C"' VColow7 Title: Teck t A4A Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A,, <br /> Application Accepted y Date <br /> Additional Comments. <br /> Phase*�t <br /> pection Q( Pas 1 ction <br /> Inspection By Date Ip_ �� -V�^ Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE /O [ <br /> �/rC)O ( Ulv►a ` tJ��l C N^ Os.o <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 10--z 73-?1P _FQ ,a�2A 3,6— /3S7 <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 />