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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> .. <br /> ° ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin,Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance wi h San oaquin Cou rdinance No. 1862 and the rules qnd regulations of the Sanauin Local Health District, <br /> wo <br /> Exact•Site Address U dtr.lti City/Town c`/ �. <br /> it4 y <br /> 13 z <br /> Owner's Name t f ✓ �" #.A Phone <br /> Address f E �.r3�w, } ':- '�1 City - t3tt„ <br /> Contractor's Name pekPo..kA.+�-' - S .. ,"�.5, License#aq <br /> P9.181 Business Phone '7 <br /> Contractor's Address 1r+ ' !�"3r .n _ r 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❑ ItIn <br /> WELLrCHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION,- PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ��✓? �� Sewer Lines Pit Privy <br /> Il Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> ,. INTENDED USE TYPE OF WELL <br /> © INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> '" 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> Ep DOMESTIC/PUBLIC ❑ DRIVENr Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> DISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL "' - Surface Seal Installed By: <br /> PLUMP INSTALLATION: ContractorI <br /> f Type of Pump = 3 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 7- t <br /> — PI hereby certify that-t`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. r <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 /> II 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 /> �y permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I.wiil all for a Grout Inspection prior-to grouting and a final inspection. <br /> Signed X � filliLt .1 >)1--� Title: L�.�@-£ `��C Date: -J ( <br /> i1 (Draw Plot Plan on Reverse Side) <br /> s* I FOWDEPA, TMENT E ONLY j <br /> '-PHASE 1 r <br /> fff i <br /> Application Accepted By -p- ]' '' —. Dale <br /> :Additional Comments: <br /> i_ Phase 11 Grout Inspection Phase III Final Inspection i <br /> i Inspection By Date Inspection By Date <br /> +:-` 1.Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑"PER SkTE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i REMIT i <br /> SICCING REMITTANCE $ <br /> BASE EXPLANATIONCHECKED <br /> DATE DATE ,REMITTED AM NT DUE AMOUNT r <br /> r <br /> ,FEE <br /> iLESS i <br /> PRORATION a 1 <br /> IPLUS <br /> -PENALTY pp1 <br /> :OTHER 3 <br /> :F .. <br /> OTHER - <br /> i 1 <br /> -�. <br /> 1Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered \ <br /> o- ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601&HAZELTON AVE.,P.O.Boz 201)9 STOCKTON,CA 95201 <br />