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Applications Will Be Processed WhenSubmittedProperly Completed. Be Sure To Sign The Application. <br /> •- �'' GFFIc_E USE: APPLICATION <br /> y <br /> (For Non-Transferable, Revocable, Suspendable) <br /> I"NVIRONM�NTAL HEALTH PERMIT PUMP&WELL(� <br /> (COMPLETE IN TRIPLICATE) �C{ SA"0� G WATER QUALITY C M 77 —3 <br /> Application is hereby made toth an Joaquin Local Health District f ra ermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 62 nd the les and regulations of the San Joaq in Lo al Health District. <br /> Exact Site Address City/Town - 40 ��126r,, <br /> L <br /> Owner's Name __ � IS akozPhone Cz�c�—6>�eq� <br /> Address �__;, �� � city -- k76 n <br /> Contractor's Name License Vq Business Phone 7 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's CompensationInsurance on File With SJLHD? Yes >41C. No <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONA PUMP REPAIR❑ <br /> REPLACEMENT❑ j <br /> DISTANCE TO NEAREST: Septic Tank AA Sewer Lines Pit Privy <br /> Sewage Disposal Field�1'5'?S Cesspool/Seepage Pit Other <br /> Property Line�[� Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL Js <br /> ❑ INDUSTRIAL >KCABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _47) <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> C t <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 4a� <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: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 certify that in the performance of the work for which this permit <br /> 112 <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 wit all tfor a Grout Inspection prior to grouting and a final inspection. <br /> Signed X /<J ��11i(rQJ4+�\ Title: rJA} �_/� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY + <br /> PHASE I Q � '7 Q <br /> Application Accepted By �`►`� _.._._ ,f—irko& �- Date �J <br /> Additional Comments: <br /> Phase II Grout InspectionhAal Inspection <br /> Inspection By �"' `�' Date—Z -7 Inspection By Date <br /> 15­— <br /> Fee <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 /> BILLING REMITTANCE $ <br /> BASE . EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by bat4 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 STOCKTON,CA 95201 <br />