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ik'ai l es Aro ass y hen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE_ U 4! APPLICATION <br /> "'^= ( r on-Transferable,Revocable, Suspendable) _. <br /> fljNY,G� 1380 ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> A <br /> (COMPLETE IN TRIP?ICT@g° !�!"1f ifil,t WATER QUALITY <br /> Application is hereby m �>> t�hppp t. QLHealth District fora permit to construct and/or install the work herein described.This application is <br /> r.� <br /> made in compliance with an Joaquin t� j�O�d�Qance No. 1862 and the rule and regulations of the San Joaquin Lod I He th District. <br /> Exact Site Address V. F - IV 0 --City/Town LOU 7L, <br /> Owner's Name Phone <br /> Address �L A ZCity -2Aaf al --t e4a J <br /> Contractor's Name 54 �R�Lt,C ` /�� L� License# cNe, l Business Phone <br /> Contractor's Address 5� .`i/��- �rc `� /D J�Emergency Phone 7,1 r� <br /> Is Certificate of Workman's Compensation Insu ance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank / d 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 /> ❑ !>DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ D VEN Gauge of Casing f (�1LL�� Ni <br /> ❑ IRRIGATION �,, /RAVEL PACK Depth of Grout Seal <br /> Il� <br /> E] CATHODIC PROTECTION [{,ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information '— %�2�•�C <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done d <br /> PUMP REPAIR: ❑ State Work Done S <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 /> 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." C <br /> I will all for a Grout,ln tion prior tp grouting and a final ins tion. y <br /> lip <br /> Signed X � 1 TI e Date: 711&0126 <br /> (Draw Plot Plan on Reverse Side <br /> ,01 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By � � Date 5 to D <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Fin nspection <br /> Inspection By J,AA( \ Date _ Inspection By Awl 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 /> AMOUNT <br /> FEE3 �( <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s <br /> Received by Dat4 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 9520 <br />