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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR QEFIC9 USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE ' may.."' WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This applica <br /> made in compliance with San Joa win County Ordinance No. 1862 and the rules and regulations of the San Joaquin Loc9I He rict. <br /> Exact Site Address �o7/J 2 11//l� h / City/Town -..7h- ,9 <br /> t <br /> Owner's Name 4FI K l �i�fL ST/`l�&,0i7 C 77�1J S. cw/~ ,17 Phone !7 I ► (-,key F`pY�- <br /> Address City C,te.,- � <br /> Contractor's Name /",�� C R ,[0r 11 4 �„ License# Business Pho e <br /> Contractor's Address /Sha Q C� Emergency Phone. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I--,' N <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDI ON❑ DFSTRUCTI ❑ ���I" <br /> WELL CHLORINATION ElWELL ABANDONMENT ❑ OTHER W PUMP IN TALLATION PUMP REPAIR❑ <br /> REPLACEMENT C1 se-lim le x05911 �I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit O <br /> Property Line Private Domestic Well Public Domestic We,, <br /> INTENDED USE TYPE OF WELL1 3 <br /> ❑ INDUSTRIAL ❑,�, SABLE TOOL Dia. of Well Excavation �� 0. <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: x Well Diameterpproximate Depth <br /> Describe Material and Procedure .0 <br /> d rX-13 J <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-contracting signature certifies the following:"I certify that in the performance of the work for.which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will cal or a Grout Inspection prior to grouting and a final Inspection. <br /> Signed X Title: �/:��S�z _ _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ey - t is ii Date +Sri <br /> Additional Comments: -> <br /> Phase II Grout Inspection Phas III Final Inspection <br /> CC-) k) / <br /> Inspection By Date Inspection By Dpte <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31/ `❑�Juty 1 &Received By July 31 <br /> f#� REMIT <br /> `�/) � BASE EXPLANATION BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O -33 /I <br /> Received by Dae Receipt No. Permit No. I uanc Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />