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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. U. <br /> Ffl,R-0FrNCE USE: 1 <br /> APPLICATION 1 <br /> R ,F- (For Non-Transferable, Revocable,Suspendable) <br /> ?ENVIRONMENTAL HEALTH PERMIT PUMP&WELL I <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY - <br /> Application is hereby made to the San Joaquin Local HealhDistrictforapermit toconstruct and/or install the workherein described,This application is I <br /> made in compliance with San Joaquin County Ordinancr)No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 2co -?—^;9IF y //gyp y ��-11 0 C�,3 7 Y <br /> /� Cit /Town <br /> Owner's Name �ie;H C1{AA0_Fe%(�t <br /> rJ CCCEVen— Phone aS� <br /> Address ZCo S 2,Z y City <br /> Contractor's Name A:�_. !/✓GZGL License#,�LBusiness Phone <br /> Contractor's Address /IAUohs-1Z Emergency Phone = <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL 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 n t <br /> INTENDED USE TYPE OF WELL 4 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 9 DRILLED Dia, of Well Casing r� <br /> ❑ DOMESTIC/PUBLIC # ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ,e�I GRAVEL PACK Depth of Grout Seal <br /> x <br /> ❑ CATHODIC PROTECTION - . ,ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface eal�nstalled By: 4 <br /> PUMP INSTALLATION: Contractor CiLfOil �c 1 <br /> Type of Pump utH P 1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: r ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 with San Joaquin County <br /> 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 forwhich 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' icing or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is is ed, I shall ploy persons subject to workman's compensation laws of California." W . <br /> I will call f a Gr I s e do prior to grouting and a final inspection. 4 <br /> Signed X - Title: P4511N)e17— <br /> '`-,Date: <br /> (D <br /> kw Plot P no Reverse Side) - J <br /> 466C-ilfCo r OR DE RTM NT USE LY ? <br /> PHAsE r <br /> Application Accepted By. ��� 7 Date <br /> Additional Comments: <br /> Phase a rouf Inspection Ph 1 Final o <br /> Inspection By Date inspection By { <br /> Fee Is Due: ❑ ANNUALL ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januar eceived By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE R TTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE L� <br /> 01 <br /> LESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY /D <br /> OTHER <br /> OTHER <br /> rt Received by ate t Receipt No. -..Permit No, Issuance Date- Malted _Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL' HEALTH PERMIT/SERVICES ay-- .1607 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />