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Ilio s*41WeAo"e n Submitted Properly Completed. BeSureToSignTneApplication. ' <br /> APPLICATION <br /> FOR OFFICE,USE <br /> - FE0 •1 81932 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL (/ <br /> VIRONMENTAL HEALTH PERMIT <br /> JOAQUIN Lom WATER QUALITY <br /> (COMPLETE IN TRIPLICAFWALTH DISTRICT <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install theworkhereindescribed.Thisapplicationis <br /> made in compliance with San.oa in C.Fty OAinance No.'1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Owner's NameLZ_ Phone ` <br /> t �{ :: city - 4.w <br /> Address _220-7 <br /> Contractor's Name � �c'sti' S A� License#��' Business Phone � t <br /> Contractor's Address <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes M No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑ DESTRUCTION❑ l �y1 <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION❑ PUMP REPAIR V 1 <br /> REPLACEMENTS <br /> 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 Weil <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 0 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 r 0 OTHER Other Information <br /> ❑ GEOPHYSICAL r Surface Seal'lnstalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ` . ® State Work Done 'Y�F^+ � 7 <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 /> 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 law of California." <br /> I itW11a Gro�ICII ���flnal <br /> inSigned X , ,. Title: Date: <br /> Plan on R1�j <br /> everse Side) ; <br /> FOR DEPARTMENT USE ONLY <br /> I *� g <br /> PHASE t ' f�LQ_ QG, Date <br /> Application Accepted By <br /> Additional Comments: — — <br /> h e II Grout Inspection Pas III Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALIY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE *EXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE c!Q <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER' <br /> - <br /> Issuance Date Mailed Delivered Received by ate Receipt No Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTOKTON,CA 95201 <br />