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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL i <br /> (COMPLETE IN TRIPLICATE) 11 WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Sara Joaq f in County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address '?4S 1!St1A1 N R042A City/Town CK <br /> Owner's Name AIAL-D 4 . G14 N ER SK. Phone 4771 �$ _ <br /> Address Aril . City sime.KMN <br /> Contractor's Name OWNER License# Business Phone V46 <br /> Contractor's Address /NS,IltptsV& Emergency Phone +&vw <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes J#._ No <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTIONq <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ 0 <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other , <br /> f <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 Cl 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 °9 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done a <br /> DESTRUCTION OF WELL: Well Diameterrr Approximate Depth h.4 k4c In <br /> Descri Material nd Procedur C 10-1 <br /> r w i <br /> i - C <br /> I hereby certify that I have prepared this application and that the work will be done in accordance w' SanJoaquin County Y <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 /> 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 forwhich this i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I� <br /> I will call for a(G�r�ou�t Inspectioior to grouting and a final inspection. <br /> Signed X —!\OS•'I^• 1dLjl.O n rT Title: <br /> Date: M <br /> (Draw Plot Pian on Reverse Side) <br /> FOR EPA MENT USE ONLY <br /> PHASEI <br /> Application Accepted By 2 Date /Z <br /> Additional Comments: j . <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By �M Date. Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Il).PER SITE _❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 <br /> REMIT <br /> BASE I EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ` DATE DATE REMITTED AMOUNT <br /> FEE nQ <br /> I� <br /> PRORATION �3 <br /> `II <br /> PENALTY PLUS J!� <br /> OTHER <br /> OTHER _ II <br /> Received by D to I�! 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 />