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w Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION p <br /> 'S. (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (C IN.TRIPLICATE) WATER QUALITY a' <br /> t.:�, ..ir:,^• r� .�,-3• y,. f..-.. .Tse-s f <br /> Applica .-s hereby made to the San Joaquin Local Health District for a permit toconstructand/or installtheworkli'ereindescribed:Thisapplication is <br /> made in compliance with San Joaquin C my Ordinance N 1 2 and the ru s and regul tions of the San Joaquin Local Health District. " <br /> Exact Site Address l t own2K� <br /> Owner's Name r Ph ne . <br /> AddressCity <br /> Contractor's Name `.License# '62790 Y13. Business Phone <br /> Contractor's Address Fr Eeyrgency'Phone �' �.< <br /> Is Certificate of Workman's CompensationIn urance on Fi h 6?U Yes _ No <br /> TYPE OF WORK (CHECK):''- _NEW WELL"' DEEPEN RECONDITION❑ .Y bESTRUC710N❑ <br /> WELL CHLORINATION ❑ WELL .ABANDONMENT..❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑` <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank e../ Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/.Seepage Pit_ Other { <br /> I <br /> 'Property Line Private Domestic Weld _ Public Domestic Well t <br /> INTENDED USE TYPE OF WELL <br /> 0 INDUSTRIAL ..: ,.� ❑.CABLE.TOO.L _ y Dia. of,Well_Excayation <br /> ` <br /> a DOMESTIC/PRIVATE DRILLED Dia. of Well Casing _ <br /> E': ❑-DOMESTIC/PUBLIC El �, �/ ? <br /> DRIVEN Gauge of Casing `�Q GL'0_"_1. <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal �? <br /> ❑ CATHODIC PROTECTION XROTARY ? Type of Grout <br /> s © DISPOSAL ❑ OTHER Other Information 4 <br /> f ❑ GEOPHYSICAL. Surface Seal Installed'B <br /> Fy <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump <br /> H.P. �C <br /> PUMP REPLACEMENT: ❑ State Work Done Pi <br /> PUMP REPAIR: ❑ State Work Done <br /> w DESTRUCTION OF WELL: Well Diameter A <br /> Approximate Depth <br /> Describe Material and Procedure V1 <br /> 1 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 9W. <br /> is issued, 1 shall not employ any person in such manner as to become.subject to workman's compensation laws of California." tin <br /> Contractor's hiring orsub-contracting signature certifies the fallowing:"I certify that in the performance of the work forwhich this N <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Insp on prior to g§outing and a final.inspection. <br /> Signed X Title: Date: lD 1z 8,3 <br /> { aw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> -- <br /> Application Accepted'By &—Mz .bate/a <br /> Additional Comments: a -+ <br /> qloutInspe � Phase III Final Inspection <br /> Inspection By Date 7 -� Inspection By Date <br /> f" � <br /> "Fee'IS DUe:'0 ANNUALLY 'Ol PER UNIT ❑ PER SITE ❑ EACH ❑ Januar 1 &Received B Januar 31 <br /> Y Y y �❑ July 1 &Received By Ju1y•31— x <br /> - BASE--�•�}••- --EXPLANATION - BILLING REMITTANCE $ REMIT <br /> - DATE DATE .REMITTED - AMOUNT DUE CHECKED <br /> AMOUNT x <br /> FEE <br /> i LESS r <br /> PRORATION rT <br /> PLUS- <br /> PENALTY <br /> OTHER <br /> _'ITHER , <br /> Date t Receipt N. .;_ :_,,.�Permit.No., .' •,,-'issuance Date Mailed Delivered _ <br /> "*`RETURN ALL COPIES TD: ENVIRONMENTAL HEALTH PERMITISERVECES 1601 E.HAZELTON AVE.,p.0.Box 2009 STOCKTON,CA 95201 <br />