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A0110tions I B Pro s d When'$ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFJCt USE: T 47M APPLICATION <br /> (For Non-Transferable,:Revocable, Suspendable) <br /> F SAN JOAQUINLQa� PUMP&WELL ! <br /> HEALTH DISTIL#}} I ONMENTAL HEALTH PERMIT <br /> 9(COMPLETE IN TRIPLICATE) � WATER QUALITY <br /> 2 a <br /> �.,, fig�. :ez �,� <br /> Application is hereby madetotheSanJoaquinLocal•HealthDistrictforkpermittoconstruct and/or install thework herein described.This application is r�X <br /> made incompliance withS pJoaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Heal h District. <br /> Exact Site Address3 vEr 1— /M./_t0 15,18 4w )E5�; City/TownJr <br /> d <br /> Owner's Name S Phone Sq9 '197 <br /> Address P11)3S. Q OAS City o v <br /> Contractor's Name ecu L✓F / ' v� �G License# DsV;L- Business Phone S'_2 7 SV//D <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELIA I DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank /�G2�� Sewer LinesPit Privy t <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line .SZ) '.Private Domestic Well leeVO " Public Domestic Well <br /> INTENDED USE TYPE OF WELL s <br /> El i <br /> INDUSTRIAL I _ ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing. 5 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . (��4 ";40 pilc <br /> 1 IRRIGATION ' <br /> J� GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: w wry <br /> PUMP INSTALLATION: Contractor Ile crr . 4e/ ?, of <br /> Type of Pump Gam' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done tf <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> _ a <br /> I hereby certify that 1 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 ar licensed agent's signature certifies the following:"I certify that in the performance otthe 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 call for a rout Inspection prior to grouting and a final inspection. <br /> p� <br /> Signed X Title: Date: D <br /> (Draw Plot Plan on Reverse Side),. _ <br /> F DEUSE ONLY <br /> PHASE <br /> Application Accepted By ARTMEN (S Date a-Z,41-gd <br /> Additional Comments: <br /> Phase It Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date ' <br /> Fee Is Due: ❑-ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTEDolor AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 $TOCKTON,'CA 95201 .- r <br />