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'—Applications Will Be Processed When SubmittedProperlyi:ompierea, oeaure 1oalylr r11w.+rM­a••­ <br /> EF01kFICE USE: �a,� lmdvo APPLICATION(For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONM€NTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COII4PLETE IN TRIPLICATE)' 3 t � <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No, 1.862 an he rule and regulations of the San Joaquin acal Health District. <br /> Exact Site ���11ff <br /> yite Address o ' -2-5?•O '. City/Town <br /> Owner's Name d?L Phone �* <br /> ll .�, /� City— �l ``r <br /> Address 76 7 <br /> Contractor's Name t License# 1`t3'��Business Phone_ Z <br /> ' �VWV' <br /> Emergency Phone <br /> Contractor's Address ao a <br /> Is Certificate of Workman's Compensation Insurance D? YesNO <br /> TYPEOF WORK (CHECK): NEW WELL❑ DECONDITION❑ DESTRUCTION[:] <br /> WELL! CHLORINATION 13WELL ABANDONMENT 1:1OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR® <br /> REPLACEMENT❑ i <br /> i DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field •Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL t4- <br /> I i ❑ CABLE TOOL Dia. of Well Excavation W <br /> ❑ INDUSTRIAL �� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 13 DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing a <br /> ❑ iRRIGATION ' <br /> ❑ GRAVEL PACK Depth of Grout Sea; <br /> " ❑ ROTARY Type of Grout <br /> f 11 C`ATHODIC PROTECTION .I <br /> 1. El OTHER Other Information <br /> ` ❑ DISPOSAL � _.. <br /> © GEOPHYSICAL a Surface Seal Ins Iled By: <br /> i PUMP INSTALLATION: Contractor <br /> t Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> 13 State Work Done <br /> ® State Work Done ��f✓G , <br /> PUMP REPAIR: - <br /> t DESTRUCTION OF WELL: ii Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 'I <br /> °I <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 /> Homeowner or licensed agent's signature certifies the following:"I certifythat in the performance of the work for which this permit <br /> t 1 is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> i 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, l shall employ persons subject to workman's compensation laws of California." <br /> ( I will call for a Grout Inspection !or t g'o i and a final inspection <br /> I w Date: <br /> Signed X t +- itle: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> k PHASE I Date <br /> Application Accepted By'� ze <br /> 1 Additional Comments: ,I, <br /> # Phase 11 Grout Inspection Pha 111 F' a inspection <br /> j '! Date Inspection By C Date 41 <br /> i Inspection By .. <br /> I 1 <br /> i Fee Is Due: ❑ ANNUALLY"1 ❑'PER UNIT. ❑ PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July'I &Receivedd By R MITuly 31t <br /> BILLING REMITTANCE s AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS a <br /> k PRORATION - <br /> 4 PLUS 1, <br /> PENALTY <br /> 1 ` OTHER <br /> I <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No. Is ante D to Mailed Delivered - - <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2409 STOCKTO 01 <br /> h T. <br />