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PMiftelolrocessW <br /> Yen SubmittedProperly complewo. tsesure Io )ign Itit:mijvl .otrv+ . <br /> FOR OFFICE US FOR �-- <br /> ��,p (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> [� <br /> L4 g*IRONMENTAL HEALTH PERMIT <br /> 3OAQVIN RIC'T'• WATER QUALITY �C <br /> (COMPLETE IN TRIPLICI$� s� �� DIST 1ST s' <br /> Application is hereby madetel�i4+J quin Local Health District fora permitto construct and/or install theworkhereihdescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 ani the rules and regulations of the San Juin ,00c I Hepdfh District. <br /> Exact Site Address �^ �]AV .�I P City/Town <br /> *.1 RC1 — <br /> Owner's Name /Y C we <br /> Address City <br /> Contractor's Name S License#mayBusiness Phone -� <br /> . <br /> Contractor's Address- '� Emergency Phone — <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes KNo <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 13 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 <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal — <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information — 1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: — <br /> PUMP INSTALLATION: Contractor — `r <br /> Type of Pump H.P, — <br /> PUMP REPLACEMENT: t❑ State Work Done <br /> L — <br /> PUMP REPAIR: S State Work Done — <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth — <br /> Describe Material and Procedure —� <br /> 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. b <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich this permit i! <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 /> I will call Gr ns p tion pr 10 g ting an final inspection <br /> Signed X +� Title: Date: <br /> (Dr w Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,{ n <br /> Application Accepted By� ("` [ms's DateS'6'�~ <br /> Additional Comments: —CM6 <br /> Phase Ii Grout Inspection PhJSQ III Final Inspection <br /> Inspection By <br /> Date Inspection By Date C•� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 it Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE HATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 — <br />