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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign The Application. <br /> FOR,o FILE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> -PUMP&WELL- `} <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Sart Joaq in County rdina No i1�j62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address � t� tom- City/Town " <br /> Owner's Name Phone ! <br /> Address City <br /> -Contractor's Name Walter H. Shoup Well Dri1liPfPnse# 376765 Business Phone 209 334-2997 <br /> Contractor's Address 7200 L Peltier Road I AcaMpla Emergency Phone 209 334-2997 �` l <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL IX 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 <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 life Outer Sore <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing lOtf <br /> [%DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 10 -ga- <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 50 .or more <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 9 sack <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump T H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ 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 y <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ~' <br /> Home owner or licensedagent's signature certifies the following:"I certify that in the performance of thework forwhich this permit <br /> is issued s all not Aploy any person in7alre)er:inf <br /> mner as to become subject to workman's compensation laws of California." I <br /> Contr s hiring r sub- ontra't si ies thetollowing:"1 certify that in the performance of the work forwhich thisper It is is d, sh oy san st to workman's compensation laws of California." <br /> I ill cal r 'ecf ptio t and a final inspection. <br /> ter Shoup Title: Contractor Date: 5-28-81 �� <br /> Signed X I <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � � <br /> Application Accepted By 1 1 t Date <br /> Additional Comments: <br /> L ha II Grout Inspection /,�� w4BY <br /> he 111 Final Enspectio <br /> Inspection By Datil �� InspectioFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1j�a ary311 my 1 &Recei By Juky 31BILLING REMITTANCE REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKEp <br /> AMOUNT <br /> FEE ' <br /> LESS <br /> PRORATION i <br /> PLUS - - <br /> PENALTY <br /> j OTHER <br /> 4 OTHER <br /> t _ i <br /> q C', -7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 5201 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITisERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 <br />