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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />PINSSE: ff APPLICATION // <br /> (For Non-Transferable, Revocable,Suspendable) ,/ <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL f� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto 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 Jopquin Local H alth District. <br /> / <br /> Exact Site Address�� .�t!�tI es rd/ Z7<" City/Town �= <br /> Owner's NamePI� �w K<' - 4„' Phone '} <br /> Address 2� _ City 1 <br /> Contractor's Name Va i/,4 r a` License# n Business Phone 3 C;r <br /> Contractor's Address . n'4 '_ < �r �:sa�� -, � ` €mergency Phone "S"X r',t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes k No Y� <br /> TYPE OF WORK (CHECK): NEW WELL IN DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ v <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ 1 f <br /> DISTANCE TO NEAREST: Septic Tank tom' Sewer Lines �� Pit Privy <br /> Sewage Disposal Field I; P Cesspool/Seepage Pit • Other <br /> Property Line"s"� Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL s <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing ` <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 4- <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 5' _ <br /> ❑ CATHODIC PROTECTION --R. ROTARY Type of Grout `-,e-A^ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: des 1��> <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done t;V <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth a <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 A <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 o <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." S <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 Ins ectio rl to grouting and a final inspection. <br /> P ep h 9 g p _ <br /> Signed X ",, -< �.�'. Title: r� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FORD PARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By ^" �— Date <br /> Additional Comments: <br /> Phase 11 Grout Inspectl-010Ph se 111 Final Inspection <br /> Inspection By �Datey� [ �lJ Inspection B q�te <br /> _ p y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING ITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> 1. DATE DATE REMITTED <br /> /' AMOUNT <br /> OK JFEE `7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 110000' 1 <br /> �s3� Yl�l�a <br /> Received by Date Receipt No. Permit No. I sua ce 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 />