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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r FOR OFFICE USE: APPLICATION 7 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> - - - PUMP&WELL <br /> i <br /> s' �~ ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install thework.herein described,This application is <br /> made in compliance with San Joaqui County dinance N 1 2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 3 Q Q O � City/Town e fG <br /> Owner's Name Phone Sl <br /> e Address # City !�,pt J:fl , <br /> ( Contractor's Name d&a e K U&f License Business Phone , <br /> Contractor's Address to AqOAI Emergency Phone <br /> Is Certificate of Workman's Compensatibn lgsurance on File With SJLHD? Yes 1�< No <br /> TYPE OF WORK (CHECK): NEW WELLPO�DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION.k PUMP REPAIR <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 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ElEls� I '� <br /> f INDUSTRIAL CABLE.TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE R DRILLED Dia. of Well Casing "!;-- <br /> El <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _45 45,T <br /> 4 ❑ CATHODIC PROTECTION ROTARY Type of Grout 1�0 7e10 !� it 7�6 — C <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sur a Seal Installed By: iA&r 07 <br /> / — <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump 4, H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r Describe Material and Procedure <br /> f 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 /> f 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." t� <br /> j 4 will cal Grout I pec n for to grouting and a final insp tion. <br /> Signed X Title: f Data: <br /> raw Plot Plan on Reverse Sid <br /> :FOR DE ARTMENT USE ONLY <br /> PHASE I 79 <br /> Application Accepted By c Date <br /> Additional Comments: <br /> P ase II rout Inspection - _,Pha§oll Final Inspection <br /> Inspection By Date '"Z!7_?9 Inspection-By _Date —/,*1^1r-e <br /> tz <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recei d By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> � � AMOUNT <br /> FEE ILA <br /> `G <br /> LESS O� r <br /> I PRORATION <br /> PLUS <br /> PENALTY - '- <br /> OTHER ��l <br /> r ..- OTHER _ W <br /> � r <br /> F Received by - Date Receipt No, Permit No. Issuance Date Mai$e_d__. 'Delivered R <br /> .- APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA g520i <br />