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' I s ,I - s BI PVc egedSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: <br /> A <br /> to APPLICATION <br /> J!t� nb�(Fo - fe <br /> Transrable, Revocable, Suspendable) PUMP&WELL <br /> 19 <br /> cr <br /> lj e7 O ENVIRONMENTAL HEALTH PERMIT ✓✓✓ <br /> (COMPLETE IN TRIPLIC "QL3#iV LOCAL WATER QUALITY <br /> Application is hereby made t,Htftrj49ac0915T fl alth District for a perrnit to construct and/or install the work.herein described.This application is <br /> made in compliance wit ;San Joaquin County Qrdinance.No. 1862 and the rules and regulations of the San oaquin Local Health.District, <br /> Exact Site Address - �A -Q--- Y l City/Town _ <br /> Owner's Name "� Phone 414. 3 © '� <br /> Address V City^� <br /> Contractor's Name �A License#A&).-3 Business Phones <br /> Contractor's Address # f ` ; Emergency PhoneC. 24 , <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes r/ 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 Sewer Lines Pit Privy v <br /> Sewage Disposal,Field c ,Cesspool/Seepage Pit - Other <br /> Property Line Private Domestic.Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 9 <br /> ❑..,/INDUSTRIAL ❑ CABLE TOOL � Dia. of Well Excavation � <br /> 1� DOMESTIC/PRIVATE ❑ DRILLED A Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN .-Gauge of Casing <br /> ❑ IRRIGATION GRAVELPACK Depth of Grout Seal <br /> �L f <br /> CATHODIC PROTECTION ❑ ROTARY �'sType of Grout a <br /> ❑ DISPOSAL 'i '1 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL } >�, '` _ urface_Seal-instal led-By.:-- <br /> PUMP INSTALLATION: j Contractor D <br /> * Type of Pump H. s <br /> PUMPa REPLACEMENT: aS`tate Work Dane <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> .IfDescribe Material and Procedure <br /> I hereby certify that-Qh ave prepared thin 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 oftom~ work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's zcompensation 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 wcall for a Gro t Inspection p for to grouting and a final ins ection. <br /> I <br /> Signed X. I �Title: .P� - Date: J V <br /> (Draw Plot Plan on Revers Side) <br /> J �, FOR DEPARTMENT USE ONLY <br /> PHASE h �L <br /> Application Accepted By � Date <br /> Additional Comments: I� t <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> -• Inspection By Date!it`, Inspection By --;WF �. -�^--- Date <br /> Fee Is Due: 11ANNUALLY- ElPER UN$T-?' PER SITE ❑ EACH ❑ January-1 &Received By January 31 ❑ 'July 1 &Received-By July 31 <br /> i <br /> REMI <br /> BILLING REMITTANCE S T <br /> t BASE' EXPLANATION - AMDUNT DUE - CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> , FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ` <br /> OTHER <br /> OTHER �' - _ r - - -•'Y - - - . - <br /> Received by Date Heceipt No. - Permit No. - issuanc 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 /> f <br />