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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> 6„y1,0 (For Non-Transferable, Revocable, Suspendable) <br /> ' .. J PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> 1 `75�D �= 8.11 ' ATER QUALITY <br /> (COMPLETE IN TRIPLICATE -- -. <br /> Applicationisherebymade tothe San JoaquinLocal HealthDis' t lot f or a permit to construct and/or instal I the work herein described.Th isapplicationis <br /> made in compliance with San����Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address QAW N. so °� sx �ar/wever��v / City/Town e Ascol e a <br /> Owner's Name f 7•e Rs Phone <br /> Address S ! City.._ [� <br /> Contractor's Name � .G License# ! City— <br /> Business Phone I ws <br /> Contractor's Addres Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fa With SJLHO? Yes k No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION © PUMP REPAIR <br /> REPLACEMENT❑ <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 Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 7 <br /> ❑ DISPOSAL ❑ OTHER Other Information _ t <br /> ❑ GEOPHYSICAL Surface Seal Installed By: A <br /> PUMP INSTALLATION: Contractor S 4&.242 / A. O <br /> ! Type of Pump__ 'Ti,✓b_2t1 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR:: fig` State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 1 i 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 5_ + <br /> F d 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." i <br /> 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, I shall employ persons subject to workman's compensation laws of California." <br /> f �w(II call for a Grout Insp io prio o g ting an final inspection. <br /> Signed dFJ / Rie: ?rgi S' Date: " f <br /> (Draw Plot Ian on Reverse Side) <br /> N .. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase ll Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection Bye 4ZOLJO'-� 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DAT REMITTED <br /> AMOUNT <br /> r FEE P Q� <br /> i LESS <br /> PRORATION <br /> ii PLUS - <br /> PENALTY <br /> t _ <br /> II OTHER <br /> a OTHER <br /> .. Received by Date. Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />