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FOR OFFICE USE: APPLICATION <br /> / (For Non-Transferable, Revocable, Sus endable PUMP&WELL <br /> P ) r' <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> (COMPLETE IN TRIPLICATE) 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 application is <br /> made in compliance with San Joaquin County,p rdinanK No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address I✓o v>�. p 'k'a �}c�,an Scot 44A t7 City/Town <br /> Owner's Name rD Y Phone <br /> Address O City <br /> Contractor's Name S1/�AJ Licensee /9a7sd� Business Phone_ �6� — 767.6 <br /> Contractor's Address Emergency Phone 4 <br /> Is Certificate of Workman's Compensation Insurance on File Wit, SJLHO? Yes No p) <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR IN (� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> L7 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 /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump T/ , o i.{-p40 <br /> PUMP REPLACEMENT: ❑ Stale Work Done <br /> PUMP REPAIR: ® State Work Done 2,:y1A ts!4( igovd e <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done ih accordance with San Joaquin County <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 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 forwhichthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout Ins act-o Nor,to g uting an a final inspection. <br /> Signed Title. <br /> 'R, al., Date: l� �y3/F-t-� <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By r Cq <br /> Dateb2 <br /> Additional Comments: <br /> Phase II Grout Inspection �Pha a III Final Inspectr,(n <br /> Inspection By Date Inspection ByC �� {e 7i6Ci <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 91 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> V <br /> Received by Date— <br /> N0. Permil No 'Issuancle Date Mailed Delmered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 96MI <br />