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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.P A Y M E N T <br /> F R OFFI t USE: APPLICATION RECEIVED <br /> p� (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> 13 ENVIRONMENTAL HEALTH PERMIT 01987 <br /> WATER QUALITY j�j� <br /> (COMPLETE IN TRIPLICATE) � p! uF�LSH <br /> ApplicationisherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindefcNbITC�ti,WYAmadein compliance with San Joaquin Co tyOrdinan No.1862 and t e rules and latio soft a San J aquin Local HeERVICES <br /> Exact Site Address r►�f A 1 "OV. Z7Y4Y7G4 irNA mcm <br /> Owner's Name CJ✓ L' RP ' T Phone- 3 <br /> Address City <br /> Contractor's Name Qom% -License# ' Business Phone a?- � <br /> Contractor's Address 1"75 11 S. 1'14J PJ Sr':.: Ca Emergency Phone = - - k <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes No40 <br /> 7 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ _ DESTRUCTION[3 <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ a <br /> DISTANCE TO NEAREST: Septic Tank IJAJ Sewer Lines Pio 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 /> r� <br /> El INDUSTRIAL 11 CABLE TOOL _ Dia. of Well Excavation <br /> [ ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing gill <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of'Casing � <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> k CATHODIC PROTECTION ROTARY Type of Grout GL-�ruT <br /> I ❑ DISPOSAL ❑ OTHER Other Information , <br /> ❑ GEOPHYSICAL Ii Surface Seal Installed By: <br /> r PUMP INSTALLATION: Contractor <br /> I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: E] State Work Do e 4It <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 <br /> ordinances, state laws, and rules 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 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 n acting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is' sued, I hall a pl 'p rsons subject to workman's compensation laws of California." <br /> X <br /> I will c f r a G ut In p do prior 10 grouting and a final inspe�in. / <br /> 1" Signed Title: - Date: <br /> (Draw Plot Plan on Reverse Side) , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ByDate -___.._-J <br /> Additional Comments: <br /> Phase II Grout Inspection t Fi I n p con <br /> Inspection By Date Q pecIon y Date 7 <br /> Feels Due: 11 ANNUALLY ❑ PER UNIT. ❑ PER SITE ❑ EACH LJ January 1 &Received By January 31 ❑ my 1 &Received By July 31 <br /> 1 BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> r LESS }. <br /> PRORATION ! <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER . <br /> r <br /> ' by Date Receipt No. _ Permit No. Issuance Date Mailed Delivered <br /> IL0.LvL-.dcANT—RETLlRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />