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mppncnuons wlu ae vrocessea wnen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> .� (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMITPUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYt; ,F <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1474 N. Thornton Rd. City/Town <br /> Owner's Name <br /> Phone <br /> Address Y _ <br /> City_ <br /> Contractor's Name - License#?2�C, Business Phone 1 <br /> ---? U 3 <br /> Contractor's Address 6 Emergency Phone --- J <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELLX DEEPEN ❑ RECONDITION Cl DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 12 PUMP REPAIR❑ <br /> REPLACEMENT❑ j <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _T <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well w <br /> INTENDED USE TYPE OF WELL `# } <br /> ❑ INDUSTRIAL ❑ CABLE TOOL +�S Dia. of Well Excavation ,_ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing 1 <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5 <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout ji q st i 1_ <br /> ❑ DISPOSAL ❑ OTHER Other Information d <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ' qr <br /> PUMP INSTALLATION: Contractor �i9J Gnv� --- <br /> Type of Pump= r2Y'S I h/e H,P. 4-- <br /> PUMP REPLACEMENT: ❑ State Work Done J J <br /> PUMP REPAIR: © 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. <br /> Home owner 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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Insper&on prior to grouting and a final inspection. <br /> Signed X 452-"l C—lill Title: Date: t I <br /> (Draw Plat Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase N Grout Inspection �h se III Final Inspection <br /> Inspection By Date Inspection By Date � <br /> Fee ISDue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Bnuar 3 Q July 1 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION E <br /> DATE DATE REMITTED AMOUNT DUCHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � ri l671o)— <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES Ti ENVIRONMENTAL HEALTH PE ITISEAVICBS 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />