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Applications Will Be Processed When Sybim tied-"erly Completed.Be Sure To Sign The Application. <br /> FOR-OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER-QdALITY <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 Jo quin Co ty Ordinan a Np. 18���d t rules and regulations of the San Joaquin Local Health District.. <br /> Exact Site Address G'Tv L!�e�5 <br /> or <br /> City/Town <br /> Owner's NameV hRK1670 Fe�B$ Cd o*f C,4- l F Phone( -- <br /> Address 7706 ( ? 5 77 City C5?,I- <br /> Contractor's Name !91�1405"1 License# 701f.?— Business Phone_ 76-9- 3 37 <br /> Contractor's Address F0 Fz,C'e Emergency Phone --t— <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONS DESTRUCTION❑ v , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy J <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 334 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ....- <br /> ❑ INDUSTRIAL CK 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 Sf}C,E • CE.fi/l`EJt/T �,�pc�/"" <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor / �f,Crgt �,�ogi r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure�� _ <br /> Thereby 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 /> Home owner 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 ca or a GrouWnspectlollt p io to grouting and a final inspection. <br /> Signed XsY' -_.. / i <br /> Title: Date: (9—An Fd <br /> (Draw Pta't"Pfan on reverse Side) <br /> PHASE 1 FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: <br /> Aal�*� _ Date `" <br /> Phase II Grout Inspection Phase III Finan Inspection <br /> Inspection By Date 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 /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> --` <br /> — FEE q3. AMOUNT <br /> LESS _. <br /> t43 <br /> PRORATION - -- <br /> PLUS - - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by ate <br /> Receipt No. Permit No. Is uance Mte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />