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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> IM <br /> APPLICATION I <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> i <br /> ENVIRONMENTAL HEALTH PERMIT J <br /> LATE) <br /> WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San JoaagOuiin�Locaton lHealth District. <br /> Exact Site Address 'Ir c corner Of Austin &, Arch rd City/Town <br /> Phone� <br /> 477-5746 <br /> I�o chez <br /> Owner's Name �'�f�C��f331 <br /> W Ro�J�.I3�'3ood Dr City <br /> Address x--5597 <br /> Clark ��,� � til License#_ �� Business Phone_ <br /> Contractor's Name E. <br /> �,�, <br /> Contractor's Address 20? E* harter Way Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPENIN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT E] C�Den ].eid� B.griE;i.Lltul al 1W ss P Pr •>? acres <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Sewage Disposal Field Cesspool/Se#page Pit Other <br /> Property Line ,0! Private Domestic Well 44100 Public Domestic Well <br /> INTENDED USE TYPE OF WELL 16" <br /> ❑ INDUSTRIAL 17 CABLE TOOL Dia. of Well Excavation 1 # <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 12 <br /> ❑ DOMESTIC%PUBLIC ❑ DRIVEN Gauge of Casing <br /> —none <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> M IRRIGATION. none <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 1:1 DISPOSAL 1:1OTHER Other Information <br /> 11 GEOPHYSICAL` Surface Seal Installed By: <br /> PUMP INSTALLA*ION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work„Done <br /> DESTRUCTION 6#,WELL: <br /> 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 /> ordinarees,'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 m k for which this permit <br /> is issued, l shall not employ any person in such manner as to become subject to workman's compensatimeation 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 fora Grout Inspection prior to grouting and a final inspection. fJCt <br /> 109 <br /> Signed X <br /> Title:1"� ,',e ..s�'res d£-nt#S�Lt` RY, Date. r <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT U ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> ! <br /> PER UNIT❑ ❑ P� El❑ EACH -Januarya-&-Received By January 31 ❑ July 1 &Removed By July 31-- <br /> Fee IS Due: ❑ ANNUALLY - <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED =- <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> --7q— 11-7-S -7 <br /> vZTs3z I � - )-7— `� <br /> Received by' <br /> ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1604 E.HAZELTON AVE.,P.O.Box 2009.. STOCKTON,CA 95201 <br />