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ApplicationswillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT c, PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) I. WATER QUALITY �f� ���/� <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or instaiI the work herein described.This application is <br /> made in compliance with Joaquin County Ordinaryge No. 186 and the res and regulations of the Sari Joaquin Local Health District. j <br /> Exact Site Address CR <br /> )'�AJ City/Town m <br /> Owner's Name YrIle. y <br /> Address Phone <br /> J f City <br /> Contractor's Name Z1.L v C/1 l+it/ License#� 9vl 0-3 Business Phone <br /> Contractor's Address,?A 60.0 t <br /> Em <br /> rgency Phone LJ N <br /> Is Certificate df Workman's Compensat or _n Insurance on File h `J1 'I16? Yes. <br /> No <br /> TYPE OF WORK (CHECK); NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> W <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ '1 y} <br /> LIST ANCE TO NEAREST: Septic Tan N Sewer Lines fy,1/✓Q- - P-it Privy A✓,--- <br /> - - Sewage Disposal Field Cd-. Cesspool/Seepage Pit cam- ther- � e- <br /> Property Line�_D_.�Private Domestic Well ublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL i� <br /> Dia. of Well Excavation <br /> BOMESTIC/PRIVATE DRILLED Dia. of Well Casing Px r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /z Ca <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> Type of Grout rr+ e ey <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11GEOPHYSICAL i s <br /> Surface Seal Installed By:. ��I..; <br /> PUMP Y- <br /> INSTALLATION: Contractor t^ <br /> II Type of Pump :•t H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: II '❑ State Work Done r <br /> DESTRUCTION OF WELL �� "'Well Diameter -' Approximate Depth <br /> Describe Material and.Proce_dure <br /> I hereby certify that Ihav 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:"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 /> ill call for a G��_4 <br /> F_Zt" <br /> spection rior Io grouting and a final inspection: <br /> - i <br /> Signed X Title: �`— Date: to �--3 <br /> (Draw Plot Plan on Reverse`Side) <br /> } <br /> FOR D ARTMENT USE°ONLY F <br /> PHASE 01t <br /> Application Accepted By Date �v <br /> Additional Comments: <br /> Phase II Grout Inspectiose III Fi al Inspection <br /> Inspection By Date�� O° Inspection By DateE <br /> i t <br /> Fee Is Dile: ❑ ANNUALLY ❑,PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> BASE '; EXPLANATION BILLING REMITTANCE $ FIEWT <br /> DATE DATE, REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS – y, .e <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER II <br /> , <br /> OTHER <br /> li 3575 (_0` <br /> Received by Date `° Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />