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Applications Will Be Processed When Submitted Properly tuomplerem Mile aura I o *HEIR I ria Mlif" <br /> II APPLICATION <br /> FOR OFFICE USE: �aawt� l� al� <br /> (For Non-Transferable, Revocable, Suspendable) PUMP & WELL <br /> 1 ° ENVIRONMENTAL HEALTH PERMIT _ <br /> (COMPLETE IN TRIPLICATE) is WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 nd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address � `� If{�� '�"��- / )) City/Town <br /> Owner's Name - �P �'►'t - I' q,.t 41:1 �- _ Phone - .. <br /> Address r - � City 66442 _ <br /> Contractor's Name S License H !y- 7 4�uSiness Phone <br /> Contractor's Address - Emergency Phone i <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL ❑ DEEPEN 11RECONDITION Lu DESTRUCTION ❑- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ Ir UMP INSTALLATION MP REPAIR ❑ <br /> REPLACEMENT ❑ U <br /> DISTANCE TO NEAREST: Septic Tank Sewer Line 's Pit Privy < < <br /> Sewage Disposal Field " . Cesspool/Seepage Pit Other . Y� <br /> ' Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE r ��� TYPE OF WELL <br /> 11 INDUSTRIAL �j ❑ CABLE TOOL Dia. of Well Excavation <br /> X DOMESTIC/PRIVATE - ❑ DRILLED Dia. of Well Casingegt.JZ - - - <br /> MESTIC/PUBLIC ❑ DRIVEN -� Gauge of Casing - <br /> ❑ IRRIGATION - N 13 GRAVELPACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION b ❑ ROTARY - Type of Grout <br /> 11 DISPOSAL 11OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> II <br /> PUMP INSTALLATION: Contractor� _ f <br /> �—� Type of Pump ro <br /> i <br /> PUMP REPLACEMENT: <br /> 13 State Work Done <br /> PUMP REPAIR; - <br /> iII L7 State Work Done <br /> II <br /> DESTRUCTION OF WELL: H. Well Diameter - Approximate Depth .A <br /> IIDescribe Material and Procedure - <br /> I hereby certify that I 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. - <br /> Home owner or licensed agent's signature certifies the following: "I certify that-ln the performance of the work forwhich this permit <br /> is issued, I shall not employ .hny person in such manner as to become subject :to workman's compensation laws of California" <br /> Contractor's hiring orsub-contracting signature certifies the lolloviing: "I certify that in the performance of the work forwhich this t <br /> . permit is issued, I shall employ persons subject to. workman's compensatiory laws of California." <br /> I dl Cali for a GroAut Ins 'ioB PNor outidg and a final inspection. 1 f - <br /> �)p._ W ( f Date: <br /> Signed 70.T3r - p _ itle: - - - <br /> li (Draw Plo TIan on Reverse Side) ; <br /> J FOR EPARTMENT LtEONLY <br /> PHASE I - '> '� S ' <br /> Dai <br /> Application Accepted By41 <br /> Additional Comments: <br /> - Phase 11 Grout Inspection 1 se trial Inspection <br /> Date Inspection B Date Z�— I F <br /> Inspection By � - - <br /> Fee IS Due: ❑ ANNUALLY ❑ �ER UNIT ❑ " PER SITE ❑ EACH ❑ January,l & Received By January 31 ❑ July 1 & Received By July 31 <br /> REMIT <br /> SASE EXPLANATION BILLING REMITTANCEI E AMOUNTOUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> rl. i <br /> LESS <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - I <br /> f; <br /> l "7 9 9 ale 'd 1 of 3 42/ 'a-_a(79 <br /> Received by " " Dale - Receipt N0. - T umuumv Date Mailed Delivered <br /> S <br /> APPLICAN - TO <br /> TRERNJ LL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1901 E. HAZELTON AVE, P.O. Box 2009 STOCKTON* CA 95201 _— <br />