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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,e FOR dFFICE USE: ;4 APPLICATION <br /> II (For Non-Transferable, Revocable,Suspendable) <br /> a <br /> I: PUMP&WELL C6-, <br /> ENVIRONMENTAL HEALTH PERMIT <br /> it <br /> { (COMPLETE IN TRIPLICATE) PWATER QUALITY i <br /> Q10 <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 AQ. ,�.. City/Towne r_ / m� <br /> ® r V <br /> Owner's Name " ms's' ,ef PhoneVim'e.R 17,0 <br /> Address a2 zra City <br /> Contractor's Name I' license# Business Phone — zr.3 7 <br /> Contractor's Address Emergency Phone ✓� — <br /> Is Certificate of Workman's Com" nsation'Insurance on C <br /> ple <br /> File With SJLHD? Yes No 7 <br /> TYPE OF WORK (CHECK): NEW WELL`M DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ `1 <br /> REPLACEMENT❑ I <br /> I! <br /> DISTANCE TO NEAREST: Septic Tank!, e er Lines it Priv <br /> Sewage Disposal Fi Id Cesspo I/Seepage Pit Other <br /> Property Line Private/Domestic Well '>< Public Domestic Well <br /> INTENDED USE I ii TYPE OF WELL i <br /> ❑ INDUST-RIAL. �� ❑ CABLE TOOL Dia. of Well Excavation_ a <br /> i. <br /> ,KDOMESTIC/PRIVATE ❑ 13RILLED- � g Dia. Well Casing <br /> t ❑ DOMESTIC/PUBLIC _ 'i+ '�❑ DRIVEN- Gauge of Casing Z-2• �O �1 U� p' <br /> r ❑ IRRIGATION �. I GRAVEL PACK Depth of Grout Seal <br /> EICATHODIC PROTECTION ROTARY _; Type of Grout G vvL W <br /> ❑ DISPOSAL Wit'❑-OTHER— Other Information �1 <br /> ❑ GEOPHYSICAL =h� Surface Seal Installed By: t Jl^i LL-e <br /> PUMP INSTALLATION: " —'Contractor <br /> 1 ' -Type of Pump H.P. C <br /> PUMP REPLACEMENT-: Ih ❑ State Work Done <br /> 3 PUMP REPAIR: ❑ State Work Done <br /> r <br /> DESTRUCTION OF WELL: _ 0ellDiameter LL Approximate Depth <br /> Describe Material and Procedure <br /> C f <br /> I hereby certify that I have prepared this application and that the work will be done in accordarice with San Joaquin County P <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 thework 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 /> •i . <br /> i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> tpermit is issued, I shall employFpersons subject to workman's compensation laws of California." <br /> I ill call for a Grout Inspection prier to grouting and a final inspection. ' <br /> Signed X Title: .V J?it✓ Date: v y <br /> �b <br /> (Draw Plot Plan on Reverse Side) <br /> •=r E <br /> FOR DEPARTMENT USE ONLY <br /> ` PHASE III -�- <br /> Application Accepte 2e <br /> Date <br /> Additional C ents: <br /> I se ll sp i Phase Ill Final Inspection <br /> Inspec By 1 Ing ection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By Janu ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> I� AMOUNT <br /> O �— <br /> I FEEf CIO <br /> ...,. - <br /> LESS <br /> f PRORATION _ <br /> k PLUS <br /> PENALTY <br /> M1 ,1 <br /> OTHER <br /> ?, ,l <br /> OTHER <br /> Received by bate, Receipt No, Permit o. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: .f,ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E.HAxELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ <br /> !I <br />