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Applications Will Be Processed When Submitted Properly Complete e�lro ig T A is <br /> FOR USE: APPLICATION ® i''�_, <br /> 0 M <br /> (For Non-Transferable, Revocable, Sus ble) <br /> ENVIRONMENTAL HEALTH P RMIT MAY 1 1980 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY Apnni� ii(Ks�lty ! `'�: I� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/o1�11�i��3..ittall ifie�iygrko'�(i�6aribed.This application is <br /> made in compliance with San Joaquin County 0rdina c No. 1862 a th rules and regulations Johan Joaquin Local Health District. <br /> Exact Site Address , 0 40.- L �7 RVI L) 9 City/Town �rt� G�/j �z�� <br /> Owner's Name m e S y r, !� Phone 8,_ — r 1 f <br /> Address /7 04 ` City ' _ } <br /> Contractor's Name 1 License Business Phone S aCv�O <br /> F <br /> Contractor's Address 00S 121,;E2""FL) Emergency Phone Lo!;-:,2e <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes– – No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION Cl DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR C1 <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 �r <br /> ❑ GEOPHYSICAL SUface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 'r 1.r _ <br /> Type of Pump _!;4_4A H.P. <br /> PUMP REPLACEMENT: ''State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth \�Q, <br /> Describe Material and Procedure <br /> a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County t <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." t <br /> I will c f r a Grout Insp n prio o grouting and a final inspection <br /> Signed X Title: Date: <br /> ` (Draw Plot Plan on Reverse Side) <br /> FOR 9EPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By L Date d <br /> Additional Comments: <br /> Phase II Grout Inspection hase III Final 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> � C L/ AMOUNT <br /> i <br /> FEE —Cis <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit o. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520(01 <br />