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4 c # x� <br /> os ss'VA?B` Prates d Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I I12� ' APPLICATION <br /> 11 (Fo Transferable, Revocable,Suspendable) PUMP&WELL <br /> D E 0 d ENVIRONMENTAL HEALTH PERMIT t �a.�� <br /> r., .9s 1 WATER UALITY ,.x ty o t- , ! `7 �--�v <br /> (COMPL TE INT !PLICATE >! Q . <br /> Application is hereby madetothe_5a Qk11 <br /> District for apermit toconstructand/or install the work herein described.This application is <br /> made in compliance with San ]oaqui�ounty 0 mance No. 1862 a the rules and�regulations of the San Joaquin Local Health District.. <br /> Exact Site Address / �`{_ /`g-� City/Town <br /> f� � yygg—� tt�� _ 4 y <br /> Owner's Name {�a-41 cN cJ. ' Phone, 73��1 tL �7"� _ ut <br /> Address 4 ' - t .. City z <br /> i <br /> Contractor's Name License#�� 3.7 Business Phone >!n <br /> Contractor's Address t Emergency Phorie �� ro IF r ` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I/ No <br /> TYPE OF WORK (CHECK): - NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _ <br /> WELL CHLORINATION ❑ WELL,ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRLY <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field . Cesspool/Seepage Pit Other ` <br /> Property Line Private Domestic Well ;;r A P6blic Domestic Well <br /> ; <br /> INTENDED USE -_TYPE OF WELL <br /> ❑ INDUSTRIAL Y❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED DIA. of Well Casing P <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gage of Casing' <br /> 11 IRRIGATION ❑ GRAVEL PACK De th of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ^, , <br /> ❑ DISPOSAL ❑ OTHER Other Information .. <br /> ❑ GEOPHYSICAL dace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ( _ H.P. 7 �_ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done ' 4— <br /> DESTRUCTION OF WELL: Well Diameter z Approximate Depth <br /> Describe Material and Procedure' <br /> /� <br /> r <br /> 1 hereby certify that I have prepared this application and4at/the`w rk will be done in accordance with San Joaquin Cousnty <br /> ordinances, state laws, and rules and regulations of e,Sa9-w/j9aquin ILocal Health District. _t <br /> Homeowner or licensed agent's signature certifies the toII6'wilhg:"I ce�ify that in the performance otthe work forwhich this permit <br /> is issued, I shall not employ any person in such an.Rgrras to become subject to workman's compensation laws of California." ,p <br /> Contractor's Hiring or sub-contracting signature certifies the following:)"I certify that in the performance of the work for which this t` <br /> permit is issued, I shall employ pe rsons;9bbjec�6'o'workman's compensation laws of California." <br /> 1 w�'�call ;aGro6t.1 Pctian bio t g�Iing and a final inspection.Signed X � �---- i11e: ��r�YL/ Daie: <br /> tN� ( haw Plot Plan on Reverse lde) <br /> FOR DEPARTMENT USE'ONLY <br /> PHASE <br /> Application Accepted By "`�" r 0 Date h 3�r <br /> Additional Comments: <br /> Phase II Grout Inspection �� pl /II Final Inspection / <br /> Inspection By- Date- Inspection By Date �r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receiv y Jan 31 ElJuly 1 &Received By July 31 <br /> BILLING .-REMITTANCE $ REMIT <br /> BASE EXPLANATION G AMOUNT DUE CHECKED <br /> DAT DATE. RE 1 r� D AMOUNT <br /> r FEE' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERVIA' <br /> ./ <br /> Received by Date 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 95201 <br />