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AppllcagonsWill Be Processed When Submitted properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE use: APPLICATION <br /> 14 'OF <br /> _ COM�p a _! (For Non-Transferable,Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) 'E=7 WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This applicatioh'2s <br /> made in compliance with San Joaquin County Ordinance No. 2862 and the rules and regulations of the San Joaquin Local Health Distri <br /> Exact Site Address s� r --�a .L Pd-- City/Town <br /> Owner's Name c 5. ,i qs ' <br /> Phone <br /> Address <br /> Contractor's Name 1 City_ <br /> License# /�3 7y'rBusiness Phone StkLG 90 - 7G <br /> Contractor's Address Sta 20 JL5 mergency Phone <br /> 1sCertificate of Workman's Compensation Insurance on File With SJ D? Yes -, No <br /> - <br /> TYPE-OF WORK(CHECK): NEW WELL❑ DEEPEN 13ECONDITION❑ DESTRUCTION❑ <br /> + WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR® t <br /> A REPLACEMENT❑ <br /> DISTANCE TO.NEAREST: Septic Tank ' <br /> P Sewer Lines Pit Privy S�I <br /> Sewage Disposal FieldCess ooi/Seepage Pit Other -4z"s_ Property Line private Domestic Well Public Domestic Well <br /> INTENDED USE-ts'v a- ' <br /> { _ TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 7 - <br /> ' -❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout -� <br /> 0 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: � � Contractor _ � �4 <br /> Type of Pump H.P.. 1` <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: - ® State Work Done ( C <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure <br /> r <br /> I hereby bertify that I have prepared this application and that the work will be done in accordance with San Joaquin County }^^ 1 <br /> ordinances,state laws, and rules and regulations4 the San Joaqu h'Eocal Health District. 7 i <br /> Home owner or licensed agent's signature�rtlfies the following:"I certify that in the performance of the work for which this permit 7777 <br /> is issued, I shell not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> In Contractor's hiring or sub-contracting signature cerliNea the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws.of California." <br /> I w I call for Grout Inspection o to u ng and a final inspection. .a <br /> Signed X ' Q" <br /> Ile: 5?jeo>f Date: <br /> (Draw Plot F91am on Reverse Side) <br /> / FO DEPARTMENT USE ONLY <br /> PHASE 1 �/j/ �/ <br /> PHASE <br /> atiob Accepted By �`L'-,b `^/�� pU <br /> Dale <br /> Additional Carnments:- 1 <br /> Phase II Grout InspePhase 111 Final Inapee <br /> Inspection By Dateate Inspection By '7-d0 -kcJ D-411 <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 1 a RecalveU By January 31 ❑ July 1 a Receivetl By July Jt ' <br /> BILLING a gEMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED J AMOUNT DUE CHECKED ' <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 4 <br /> PENALTY " <br /> OTHER. <br /> OTHER <br /> 271 6 <br /> Receivetl by D. Receipt No, Parmn NP. Iuan a Date Mallatl Oellvaretl <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 16111 E.HAZELTON,AVE,P.O.Box=2 STOCKTON.CA 95201 <br />