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rr•*.o11lLPns wttrbeProcessedWhen Submitted Prpperly Completed. Be Sure To Sign The Application. <br /> FOR FFICE USE: - <br /> 4 APPLICATION <br /> �b <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is herebymade totheSanJoaquin Local Health Districtfora Permit to construct and/or install the work herein described.This ap application <br /> made in compliance wit an oaquin County Ordinance No. 7 62 and the rules and regulations of the San Joaquin Loc-al ealth District. <br /> Exact Site Address 3 ' �'*T' f P Is <br /> c c <br /> !l City/Town S <br /> Owner's Name —13 1& (Zvi 'PI-ict� <br /> Address li� Cit M- Phone Q <br /> Contractor's Name C C•i� City 'fir <br /> Contractor's Address 20- 4957, License#] Business Phone <br /> Is Certificate�ur Emergency Phone _. —M�� <br /> of Workman's Complensation I sur ce on File With SJLHD? Yes <br /> f TYPE OF WORK (CHECK): NEW WELL DIEEPEN ❑ No <br /> r WELL CHLORINATION ❑ '' RECONDITION❑ DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ <br /> REPLACEMENT❑ IUI l PUMP REPAIR <br /> DISTANCE TO NEAREST: Septic Tanks C /IJ SEX Lln O- <br /> Sewage Disposal Field Pit Privy /" a <br /> Cesspool/Seepage Pit Other <br /> Property Line/0 �Private Domestic Well INTENDED USE �TYPE OF WELL � Public Domestic Well <br /> ❑ INDUSTRIAL ❑ CABLE TOOL6 <br /> DOMESTIC/PRIVATE Dia. of Well Excavation <br /> 13 DRILLED <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Dia. of Well Casing <br /> � <br /> ❑ IRRIGATION ,,,,,,���CCC 1• Gauge of Casing S <br /> El ❑CATHODIC PROTECTION AVEL PACK Depth of Grout Seal `� f <br /> ❑ DISPOSAL I` OTARY Type of Grout [ �. <br /> ❑ OTHER <br /> 13 GEOPHYSICAL Other Information <br /> t <br /> PUMP INSTALLATION: Contractor Surface Seal Installed By: <br /> j Type of Pump { <br /> PUMP REPLACEMENT: I ❑ State Work Done H.P. <br /> PUMP REPAIR: El State Work pone <br /> DESTRUCTION OF WELL: - _ <br /> Well Diameter <br /> 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 wi <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. th San Joaquin County <br /> Home owner or licensed agent's si n nature certifies the following: + <br /> is issued, I shall not em ID an g g="I certify that in the performance of the work for which this permit <br /> p Y Y person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or subcontracting 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." d <br /> I will call for a Grout Inspection irlor to grouting and a final inspection. <br /> I ' <br /> Signed X = <br /> Title: R'jR <br /> (Draw Plot Plan on Reverse Side) Date: ! <br /> PRASE I FOR DEPARTMENT USE ONLY <br /> I <br /> I <br /> r <br /> Application Accepted By ` <br /> Additional Comments: �M Date 77 <br /> s <br /> Phase it"Grout Inspection ` <br /> Inspection By u Date Phase III Final Inspection <br /> ;I Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑'iPER UNIT <br /> PER SITE ❑ E� anuary 31 ACH ❑ January 1 &Received By J <br /> T ❑ July 1 &Received By July 31 <br /> -" BASE i�' EXPLANATION all-LINGREMITTANCE $. REMIT <br /> IIIA „DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE �!' AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY n <br /> OTHER <br /> OTHER <br /> I <br /> Received by DateReceipt 9 Lip 19/1,-1-79No, Permit <br /> APPLICANT—RETURN ALL-COPIES TOi� ENVIRONMENTAL HEALTH PEAMIT/SERYICES Issuance Date Mailed Delivered <br /> - 1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON,CA_96201 + ` <br />