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Applications Will Be Processed When Submitted Properly Completed. Be Sure Ta Sign Mite A pli�atlgn. �� <br /> oFtr: E USE: APPLICATION Ili ,illi A V 7 <br /> M (For Non-Transferable,Revocable, Su <br /> spendable) � PUMP&WELL <br /> ii <br /> ENVIRONMENTAL'HEALTH-PERMIT SEP 14 19$1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 4....SAN . 0t t' <br /> Application is hereby made to the San Joaquin Local Health District fora perrriit toconstruct and/or install the wpl k l e �e. nlYe �s application is <br /> .t 7C.�t., d t I I1 t�' . <br /> made in compliance with 5 Jo in Coun�}Ordinance No. 862 and the rules and regulations of the San Joaquin Loc �' ea �istrict. <br /> Exact Site Address-*� /� �'�/ Qy e City/Town <br /> Owner's Name r' As z f"' Pl a ,.r; Phone �� Z <br /> Address ii i O <br /> "s city-, C vl <br /> Contractor's Name OP, 't Licerfse#- Z usiness Phone' <br /> Contractor's Address *° ''} Emergency Phone <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes_ No --- <br /> TYPE OF WORK (CHECK) NEW WELL 'DEEPEN ❑ RECONDITION❑- DESTRUCTION❑ - I <br /> - r � <br /> WELL CHLORINATION ❑- WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR-L] W <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy i <br /> Sewage Disposal Field * . Cesspool/Seepage Pit Other <br /> Property Line_O&C Private Domestic Well f Public Domestic Well <br /> .. INTENDED USE TYPE OF WELL �, Z <br /> ❑ INDUSTRIAL �; ❑ CABLE TOOL Dia. of Well Excavation - w <br /> ' r <br /> DOMESTIC/PRiVATE if ❑ DRILLED Dia. of Well Casing 1 '` <br /> © DOMESTIC/PUBLIC C1DRIVEN Gauge of Casing r <br /> ❑ IRRIGATION - i UKGRAVEL PACK Depth of Grout Seal t f <br /> ❑ CATHODIC PROTECTION X ROTARY. Type of Grout em <br /> i <br /> ❑ DISPOSAL ❑ OTHER Other Information # t' <br /> ❑ GEOPHYSICAL '� Surface Seal Installed By: i 1 <br /> PUMP INSTALLATION: A. Contractor_.., I L _ <br /> Type of Pump . <br /> PUMP REPLACEMENT: '� ❑ State Work Done_ '? - H. <br /> g <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ij Well Diameter »-- Approximate Depth i't <br /> Describe Material and i <br /> k� _ .., <br /> 17 <br /> I hereby certify that I have prepared this application and that the wo"r�will be donwe in,raccordance with San Joaquin County <br /> ordinances, state laws, and rules and regulationsrof 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 sudh manner as to become subject to workman's compensation law's. of California." s <br /> C ractor's h g or sub-contracT g sigh ^r certifies the following:11 certifythat in the performance of the work for which this <br /> ermit is issued, sh II employ p s� bje to workman's compensation laws of California."will call f r t Inspe ti r uting Inal Inspe p `i-Signed X �. Title: / x4r <br /> Date:, <br /> i� s (Draw Plot Plan on Revers Side) E.. `+ <br /> SE I <br /> FOR DEPARTMENT USE ONLY I <br /> PHA <br /> Application Accepted By Date <br /> Additional Comments: `� } r �+ <br /> Phase It Grout Inspe1.ction f h III F' I Inspection <br /> Inspection By 1 -Date a 1ljc0''pec <br /> tion By- Date ��� <br /> Z-.fl <br /> "Fee IS Due: ❑ ANNUALLY PER UNIT ❑-PER°SITE'':= fl EACH "'0"-January 1 &Received By Ja aP.y 31 ❑ J*u 1 &Received By July 31 <br /> i: BASE II 'EXPLANATION .BLrL`•.I4!�- <br /> I <br /> REMITTANCE $ ! REMIT <br /> ii CHECKEDDATDATE REMITTED <br /> AMOUNT DUE : AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS " <br /> PENALTY ! <br /> OTHER n,. ! - <br /> OTHER <br /> 13 a-(o <br /> Received by - Date h - Receipt No-- Permit No. - '.Iss ance'D to .. Mailed Delivered �. _ _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />