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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> r (For Non-Transierable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELLti <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY W . <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 s <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 ._ 10S, / ?V4 <br /> City/Town �/�G 5- <br /> Owner's Name ;Vel 12.0 r. 014? 4/ Phone <br /> Address City <br /> Contractor's Name 1,ap,c_/,fA.'/ne.� �s7�ir, ,.40esLicense#_$fo9_-VL Business Phoneme=/ <br /> s' Contractor's Address, r n2 j�a..v Emergency Phone 753—4 0 <br /> Is Certificate of Workman's Compensation Insurance on File Wit�HD? Yes_' No <br /> TYPE OF WORD( (CHECK): NEW WELL 19 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ w <br /> t WELL CHLORINATION ❑ WELL ABANDONMENT 'OTHER ❑ PUMP INSTALLATIONX PUMP REPAIR❑ <br /> REPLACEMENT❑ y ^ . . ... - .-- - _ + <br /> DISTANCE TO NEAREST: Septic Tank lda Sewer Lines �lGe�' -,Pit Privy <br /> Sewage Disposal Feld-Z/-00 Cesspool/Seepage-Pit 4 Other <br /> Property Line" Private Domestic Well ZS : . Pubhc Domestic Well X40 <br /> I INTENDED USE TYPE OF WELL _r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL. Dia. of Well Excavationes-_ <br /> 1 ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of W611';Casing. <br /> 19 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of-Casing C,4",w "d <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal =J22 ` <br /> ❑ CATHODIC PROTECTION ,Z ROTARY Type of Grout- ro.ur.Lv <br /> ❑ DISPOSAL +❑ OTHER Other Information. dl <br /> . ❑ GEOPHYSICAL . ;Surtace Seal Installed By: "4­1 <br /> PUMP INSTALLATION: Contractor <br /> f. Type of Pump <br /> 1 /2� ._ H.P. r2 <br /> •A PUMP REPLACEMENT: ❑ State Work Done <br /> ti PUMP REPAIR: ❑ State Work Done' <br /> s _[DESTRUCTION OF WELL: Well Diameter ti Approximate Depth l0� <br /> { ' <br /> Des ibe Material and Procedure <br /> �'• .�Ta�r� � -.�.���-sem_ <br /> 4. I hereby certify that I have prepared this application and hat the work will be done in accordance with San Joaquin County <br /> 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 ofthe 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." s' <br /> t Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> I J permit is issued, I shall employ persons subject to workman's compensation laws-of California. _ <br /> r I will call for a 'rout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: 27,2&'7;F <br /> (Draw Plot Plan on Reverse-Side) <br /> FOR'DEPARTMENT ONLY <br /> a PHASE I �,� p <br /> Application Accepted By ems"lk bate G� 7 <br /> Additional Comments: <br /> j Phase It Grout Inspee lon (�h4sAIII Final Inspection f11 <br /> Inspection ByRate nspec tion By ` ate <br /> 11 9 9 1ZvAQca <br /> Fee Is Due: El AN ❑ PER UNIT PER SITE tACW ❑ January 1 $neceived By January 31 © July 1 $Received By July 31 <br /> s <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED .y <br /> t AMOUNT <br /> FEE g a U O } <br /> f , <br /> I LESS f <br /> PRORATION <br /> { PLUS <br /> PENALTY }} <br /> ( OTHER 1 <br /> OTHER 111 <br /> Received by Date Receipt No Permit No, Issuance Date Mailed Delivered <br /> APPLICANT=RETU."R ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009�STOCKTON,'CA 95201 - <br />