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Applications Will Be Processed When,$ubmittpd Properly Completed. Be Sure To Sign The Application. <br /> FOR,OFFICE-USE: APPLICATION ) °% // " ,; t' <br /> (For Non-Transferable, Revocable,Suspe dable) M ra <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i <br /> (COMPLETE IN TRIPLICAT /���2 / ��' �IN TER QUALITY ) <br /> Application is hereby ma to the San Joaquin Local Health District a permitto constr t and/or install the rk herein described.This application is <br /> made in compliance w' San Joaquin Count Ordinance No. 1862 and the rules and regulati ns of the an Joaquin Local ealth District. <br /> Exact Site Address [ ,0,V e ? ity/Town33 <br /> Owner's Name4 i r edl Phone g/ e? -gveft <br /> Address (®AQ c7czk 42ae City 40 Aeu-,erlee., <br /> Contractor's Name A. P7. 45'"V &_AeL� 4tolfl;.If License# .10f+t Business Phone <br /> Contractor's Address 916q ,y.• :/'' /,;W C r Emergency Phone 7Y 4, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Gl No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /S Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lined 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 `a �- <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 17 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Xif1 - �j�p,Ar <br /> PUMP INSTALLATION: Contractor �p <br /> Type of Pump S_�16 H.P. 16 N <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 16 <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 will call for a Grout Inspection rior to arouting and a final inspection. <br /> Signed X 0 Title: Date:l-44 <br /> 011- (Draw Plot Plan on Reverse Side) <br /> F R DE ARTMEN USE ONLY <br /> PHASE I � <br /> Application Accepted By �'^ d� Dated <br /> Additional Comments: —4 <br /> Pt�sGroutylspection , Ph Final pection <br /> Inspection By,-�'A''1;� ,� .r 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ill 30 56 <br /> Received by Date Receipt No. Permit No. 'Issuarice 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 />