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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FORQFFICE USE: APPLICATION <br /> - (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL. HEALTH PERMIT d PUMP&WELL <br /> COMPLETE IN TRIPLICATE •` ;fp <br /> Application is hereby madetotheSa�JoaquinLocal Health Districtfo t't ructand/or install the work herein described.Thisapplicationis <br /> made in.compliance;with Sa TinCountyOrdinance No. 1862 and a rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address t! C�Q �'!ll 14 City/Town Vfs.. .i-�_ t25 1—>rl d �} <br /> Owner's Name @. 9-7 Phone A <br /> Address . / 5 aF e4 P% RIC City J i ` <br /> I` Contractor's Name ` 1 icens-e#JI?31;L 4,"vBusiness Phone 7 cl% '" 13 <br /> Contractor's Add raQ 5_r17' kfiergency Phone 5.I. /V-•t-.a <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4___� No <br /> TYPE OF WORK (CHECK): NEW WELL©--' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0" PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines /5�"(� 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation � - <br /> G <OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing , - <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0-MTARY Type of Grout 9 ipp <br /> ❑ DISPOSAL ❑ OTHER Other Information rl <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor et;m C_,_n wisni J _ Z_ <br /> Type of Pump H.P. 73 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: T ❑ State Work Done <br /> DESTRUCTION OF WELL: '� Well Diameter Approximate Depth <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 <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 <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:1 certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. ( - <br /> Signed X Title: -� 5=-+.rs� S�� :� Da <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By �� Date Z <br /> Additional Comments: <br /> P s II Gra Inspection Phase 11 Final Inspection <br /> Inspection By Date _ Inspection ByDate <br /> Fee Is Due: ❑ ANNUALLY ❑ PERU IT pER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Datk Receipt No. Permit No. Issuance Date Mailed De' >tid <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201 <br /> _ I <br />