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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa°ium County Ordinance No. 1862 and the rules and regulations of the San JoaquinH a <br /> L cal <br /> � lth District. I <br /> Exact Site Addres/s� 3 76L. <br /> 4 City/Townv��� <br /> Owner's Name <br /> L Z, � C. "UI-0 ks Phone — <br /> Address Gni • �L D City �� <br /> Contractor',s Name C,L. IJELk � 1 _ License# S Busi�s Phone Z- r <br /> Con,''e s s Address Z w Emergency Phone _ <br /> Is Certificate of Workman's Compensationilnsurance on File With SJi Yes �— No I I <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONS [(� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ ` <br /> REPLACEMENT© l I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Fi Cesspool/Seepage Pit Other <br /> Property Line+Private Domestic Well Public Domestic Well <br /> INTENDED USE �;� TYPE OF WELL / Y <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation— <br /> +� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing � G <br /> ❑ DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing 17. <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout �`E''`'� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> r. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -4- <br /> Describe Material and Procedure <br /> i1 r <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 rule's and, regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework for which this permit <br /> is issued, I shall not employ alit' 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." <br /> I i I II for yprgut Inspection prior to grouting and a final inspection. <br />' Signed X _ -v r Title: - Date: Z•1 J'4 L <br /> rr <br /> (Draw Plot Plan on Reverse Side) <br />' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date I <br /> Additional Comments: <br /> Phase II Grout Inspection-} -Pe-w,5 d« wQ�� Phase ill Final Inspection <br /> Inspection By W, Date Inspection By Date <br /> py <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> SASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> I 3 <br /> l FEE <br /> ' 4 <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> a <br /> Received by -�..Date .+;L Receipt No Permit No. -�I uance Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2008 STOCKTON,CA 45201 <br /> i <br />