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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign IneAPPllcauon. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPL.ETE,A-19 TRIPLICATE) WATER QUALITY <br /> ApplicationThis its hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described. s application is <br /> made in compliance with San Joaquin C;vnty Or mance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> b vZ /v City/Town +`�P "D t. <br /> Phone 36 F.— C> 7 <br /> Owner's Name �' <br /> 0 <br /> Address City <br /> Contractor's Name r iAJ License#� yd Business Phone <br /> "M 0 Emergency Phone <br /> Contractor's Address <br /> �� <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 4 UJ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11PUMP INSTALLATIOI PUMP REPAIR❑ } �4 <br /> REPLACEMENT❑ _ ~JL~ S` <br /> DISTANCE TO NEAREST: Septic Tank <br /> r Sewer Lines Pit Privy { <br /> Sewage Dis os I Field 6 A Cesspool/Seepage age Pit Q �� Other <br /> A. S ublic Domestic Well /)� <br /> Property Li perms Private Domestic We <br /> INTENDED USE TYPE OF WELL �s ri 0 ; <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> e� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing " s <br /> ❑ IRRIGATION ' ❑ GRAVEL PACK Depth of Grout Sea, <br /> ID CATHODIC PROTECTION El ROTARY Type of Grout '� rrjG�� <br /> -❑ DISPOSAL ❑ OTHER Other Information <br /> SSeal stalle B <br /> ❑ GEOPHYSICAL rr ,I/{} r�i, �iKZ, <br /> PUMP INSTALLATION: Contractor L(�CadfGh- �! —'Y <br />{ "Me'- <br /> Type of Pump _b H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done k <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> r Approximate Depth <br /> Describe Material and Procedure <br /> I here -the work will be done in accordance with San Joaquin County <br /> by certify that I have prepared this application and that <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 torwhicIT this permit <br /> is issued, I shall not employ any person in such manner as of become subject to workman's compensation laws of California." <br /> l Contractor's hiring or sub-contracting signature certifies the`follbwing:"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 Grokit Inspection rior to grouting-and a final inspection. <br /> Title: Date: ' <br /> Signed X <br /> (Draw Plot Plan_on Reverse Side) <br /> _ FORD ARTMENT USE ONLY <br /> PHASE 0171-4,2 <br /> �'Application AccepDate� �� 3Additional Commeut Inspection qAh s III Final InspeInspection By Date 6 92- Inspection By Date <br /> I Fee Is Duel ❑ ANNUALLY- _-E]�❑ PEO UNIT '❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING_ REMITTANCE $ AMOUNT DUE CHECKED <br /> -PATE DATE REMITTED AMOUNT <br /> I FEE _ <br /> { LESS <br /> y PRORATION <br /> PLUS <br /> t PENALTY f ' -7 f + <br /> OTHER t L-��(+ L .r <br /> OTHER - <br /> Received by - <br /> Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES,'`� 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,'CA 95201 <br />