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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> t FOR OFFICE USE: APPLICATION <br /> w (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> I <br /> COMPLETE IN TRIPLICATE QUALITY <br /> Application is herebymadetothe n oaquinLocalHealthDlstrictf er It to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San oa uln Lo al Health District. <br /> I Exact Site Address !! � S- �/V/�!_%� City/Town SFr <br /> Owner's Name !tS Ivy Phone <br /> j Address 1111 NOWLAPP R64D City H" ,�edq <br /> Contractor's Name 6LARX WLL d 94UI P 1�icense#��� Business Phone �G x-~ r���7 <br /> Contractor's Address UI L GAARM W4 Emergency Phone LZ-G2.3 6 <br />! Is Certificate of Workman's Compensationrinsura File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION.❑ _ ,WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ y <br /> 7 <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 <br /> INTENDED USE TYPE OF WELL Q '00, ►t <br /> 3 D❑ I RIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> TIC/PRIVATE i.E1 DRILLED Dia. of Well Casing ` <br /> ❑ DOMESTIC/PUBLIC }❑ D5W� Gauge of Casing _ <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 8dlrPffW1Ix <br /> 1 <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 0� <br />+ PUMP REPLACEMENT: ❑ State Work Done <br /> K PUMP REPAIR: ❑ 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 /> 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 for which this <br /> permit is issue , I shall a oy persons subject to workman's compensation laws of California." <br /> I will a Grout I ction prior grouting and a final inspection. <br /> Signed X Title: �wV�lll Date: .5 Qadu <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE O <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date _ Inspection By Date <br /> "e�/ <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ RE,SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - ; _ AMOUNT <br /> FEE -3 �D - . © ; <br /> LESS <br /> PRORATION l <br /> PLUSPZ <br /> �. PENALTY f ' <br /> - OTHER <br /> } <br /> E OTHER <br /> AA kZ; <br /> q— %% 0 1a /41l ?`t <br /> Received by Gam ]{ Receipt Ni). Permit No. Issuance Date Mailed Dekivered v <br /> APPLICANT--RETURN ALL COPIES TO:,-( ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE._,P.O.Box 2009 STOCKTON,CA 952011 -_ <br />