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Appliea Itj I PLpfe+�YVF�1@ aied Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE: r d�"ggPLICATFON <br /> ly DEC 2 (F1'o�qrJ Non-T �bie; Revocable;Su+spendable) PUMP&WELL <br /> I% EiQ�iRONMENTAL HEAL-_t '-PERMIT <br /> (COMPLETE IN TRIPLICATE) SAN' I_ Itg �+r+ryryF WATER QUALITY <br /> v:A L. �: .-,...` ri.e r, iz i'-�. <br /> Application is hereby made to the Sa�t�t�n�d riTrjLO&S"�strictforaperrrilttoconstructand/or.install the work herein,described.This application i <br /> made in compliance with San Joaquin-County Ordinance.No. 1862 and the rules.and regulations of the San Joaquin Ll Health District.. <br /> Exact Site Address J� i�,uye:,, "'" v M <br /> City/Townr Local <br /> Owner's Name .,•+. aS+7 1x .-.. <br /> Pho�� <br /> ne r' € <br /> Address <br /> City <br /> Contractor's Name ' r "License# _2373 - 'Gusiness Phone 96_75;. _1 <br /> J <br /> Contractor's Address I"G ; ' ' J1 t Zc i ifV Emergency Phone! w_ ?• .OJ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes v I _ No <br /> TYPE OF WORK (CHECK) NE1W WELL❑ DEEPEN ❑ •RECONDITION❑_ DESTRUCTION❑ " <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR©r- T —' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 'Cesspool/Seepage Pit -4Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE .TYPE OF WELL <br /> ❑ DUSTRIAL l ❑ CABLE TOOL Dia. of Well'Excavation x <br /> u DOMESTIC/PRIVATE �I ❑ DRILLED <br /> _ Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION j� ❑ ROTARY Type of(Grout <br /> ❑ DISPOSAL I ❑ OTHER <br /> I Other Information <br /> ❑ GEOPHYSICAL :L r Surface Seal Installed By: <br /> PUMP INSTALLATION: pp Contractor <br /> II Type of Pump H,P. <br /> PUMP REPLACEMENT:' Vii. ❑ State Work Done <br /> PUMP REPAIR: II 0-State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter t Approximate Depth p�jN <br /> II Describe Material and Procedure t' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County L <br /> ordinances, state laws, and rules and.regulations of the San Joaquin Local Health District. <br /> Home owner or Ilcensed agent's.signature.certifies the following:"I certify that in the performance of the work for which this permit s� <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." w <br /> Contractor's hiring or subcontracting 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." I <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: 2 l <br /> (Draw Piot Plan on Reverse Side t• y j <br /> C= _ .- - <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> ;Application Accepted By Date ' <br /> Additional Comments: II t i <br /> Phase 11 Grout Inspection ti f J�hase III Final Inspection <br /> inspection By Date - Inspection B <br /> p Y' ate- <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH "January 1 &Received By January 31' ❑ July 1 &Received By Jury 31 <br /> BILLING REMITSANGE REMIT <br /> 'BASE' EXPLANATION �'°` - AMOUNT'DUE CHECKED <br /> -i 15 DATE DATE; REMITTED <br /> - AMOUNT <br /> FEES <br /> LESS <br /> PRORATION - <br /> PLUS ,/ <br /> PENALTYISG 6 6� e 4c S I � Cv c•f <br /> OTHER <br /> 1.- LVGC/��`aC•�I �./f��.c 1j{. 'GLy /j Lr X <br /> OTHER T -- <br /> _ Received by - Date- a6 _ <br /> i Receipt No. Permit No. - - Iss anceDatMailedr Delivered - " <br /> APPLICANT—RETURN ALL COPIES TD: ENVIRONMENTAL HEALTH PERMIT/SERVICES 7801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> l� <br />