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L FOR OFICICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) i <br /> PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> L(COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereoy made to the San Joaquin Local Health District for a permit to construct and/or instal l the work herein described.This app . <br /> made in compliance with San Joaquin County�O jdina9ce No. 1862 and t e ules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ���3a � .c.J/T2`I` V-;K z � City/Town /TIMI r»P O <br /> LOwner's sNNam,e L I N G <br /> Addresselli.Z O _ AJ 7 Vcc <br /> I, � '_ City ert" X, .0 <br /> LContractor's Name u VIC IJt License#3481 Zk3 Business Phone Ie F <br /> Contractor's Address��o°Q .5oWIfS /9'CA /�'10GEmergency Phone /Vd/ll 4- <br /> Is Certificate of Workman's CompensationIn ranee on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _ <br /> LWELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11PUMP INSTALLATION. PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank .S'�-o �J�� Sewer Lines/B�Y-Y— Pit Prjvy �-- <br /> Sewage Disposal Field lf119 A� Cess ool/Seepage Pit o AJ-� Other <br /> L Property Lin—Private Domestic Well&d&­ Public Domestic Well IJO.C/112— <br /> INTENDED USE TYPE OF WELL �/ <br /> p ❑,INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> `. DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> L ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Ceara <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL / Surface Seal Installed By:, <br /> L PUMP INSTALLATION: Contractor » <br /> Type of Pump ISO /d H.P. <br /> r r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ill' Describe Material and Procedure Cil <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County l!1 <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 fallowing:"I certify that in the performance of the work 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 /> Contractor's hiring or sub-contracting signature certifies the following:"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 /> 1 wl call for a Grout Ins If prior to grouting and a final inspection. <br /> Signed X ��j �� �t � Title: ` — 47.4J-,'41 .L/ Date: <br /> V (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By p, �f�� ' 1 r��- O I Date ' <br /> Additional Comments: <br /> II Grout Inspection O hasp F al Inspectio664- <br /> Inspect <br /> 6 8 <br /> Inspection By Date Inspection By to <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ` BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> L OTHER <br /> OTHER <br /> Received by Data I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES teen E.HAZELTON AVE,P.O.S.2 STOCKTON,CA 95201 <br />