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Ap licatignS',W,ill;Be`Prlfaessed ubmitted Properly Completed. Be Sure To Sign The Application. <br /> I kl <br /> FOR OFFICE USE: � �; � L APPLICATION <br /> ( c. _. P <br /> (For N ansferatile, Revo'rcable',Sus endable) PUMP&WELL <br /> f DEC 5''•1, f s 1VIRONMENTAL HEALTH`PERMIT v <br /> (COMPLETE IN T IPLICATE .WATER QUALITY <br /> Application is herebymadeto Lilo q` t SAW= ibist,i,tfor apermit toconstruct and/or install the work_herein described.Tliisapplication is <br /> CA <br /> made in compliance_with San JN Hnt�r WI No. 1862 and t e,rules an regulation of the San Joa uin Local Health District. <br /> Exact Site Address r it /Town k �i -��r.- _ I <br /> Owner's Name7gp ap : Phone" � �e �C�7 <br /> Address a : D 4b,,- ►- City 7' _._-. <br /> Contractor's Name " y <br /> ''License#/(- Business Phone <br /> Contractor's Address - L <br /> ••. . Emergency��Phori- e-` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 'f No <br /> TYPE OFIWORK (CHECK): NEW WELL❑ w. DEEPEN ❑ — RECONDITION❑__� DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ _ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines A Pit Privy <br /> Sewage Disposal Field Cesspool/Seepag it Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> C~ INTENDED USE TYPE OF WELL Y w <br /> ❑ INDUSTRIAL ❑ CABLE TOOL - Dia. of Welli'Ezcavation - - <br /> F" ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well;Casiing r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal_ L• i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL © OTHER Other Information <br /> ` ❑ GEOPHYSICAL Surface Seol Installed By: <br /> PUMP INSTALLATION: Contractor 10 ll� <br /> Type of Pump g _ H.P._ ri <br /> PUMP REPLACEMENT: ❑ State Work Done s <br /> PUMP REPAIR: L`State Work Done i - Y `1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - �-� Describe Material and Procedure f <br /> - and _unn -- <br /> i �: I h� yi�`e''fi ify'that'I"�'+Te,par�"8'tYTis p icafion IT`fa`the work wiTT-b dbne-in accord-ante wifFi'�Sa`n Joaquin Coty \ <br /> T ordinances, state laws, and rules and regulations of the-San Joaquin Local HIth District. w <br /> Homeowner or licensed agent's signature certifies the following:"I certify that i the performance of the work for which this permit <br /> § is issued, I shall not employ any person in such manner as to become subject1to 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 /> ` 7 permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> k I will call fora Grout Inspection prior to grouting and a final inspection:- <br /> Signed X Hie: Date <br /> (Draw Plot Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By � V Cg7--. Date `3f`�f'� <br /> Additiorial Comments` <br /> Phase II Grout Inspection Final Inspect' <br /> on2— $3 <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: El ANNUALLY El PER UNIT 11 PER SITE <br /> 11 EACH ElJanuary&+Received Janua 31' ❑ July t R Received By July 31-' <br /> � REMIT <br /> BASE EXPLANATION BILLING REMITTANCE /� AMOUNT DUE CHECKED <br /> DATE DATE tl 'MIA AMOUNT <br /> FEE' <br /> o. <br /> t <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER - w. - -t 1,� - <br /> I € <br /> 3 C> y/a_:i� <br /> Received by Date Receipt No. Permit No. Issuance Date -Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES .1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />