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Applications Will Be Processed When Submitted Properly Completed.Be Sur S�g�1 TtSe�AJppcatfon.L r�� <br /> FOPOFFICE USE-— <br /> APPLICATION n _ <br /> (For Non-Transferable, Revocable,Suspendable) APR 9 �g$� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> tM <br /> 'OPLETE IN TRIPLICATESAN JOA.QUIN LOCAL <br /> ) WATER QUALITY HEALTH DISTRICT t <br /> � pplicationisherebymadetotheSanJoaquinLocalHealthDistrictforapermit_toconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County dinance N9 1$52 and the rules and regulations of the San Joa um Local Health District. <br /> • Exact Site Address � �G� �-�, 4(� r...s •-� 1 <br /> City/Town n �_ <br /> Owner's Name Gh/ --.— Phone CT <br /> Address City + <br /> Contractor's Name License ti 4FAU-3 Business Phone 7 <br /> Contractor's�( g �J'p r5w to Emergency Phone I i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ o ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS L <br /> REPLACEMENTC� <br /> DISTANCE TO NEAREST: Septic Tank /0 d Sewer Lines_ !�Q Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> • 1 <br /> Property Line _Private Domestic Well Public Domestic Well a, <br /> INTENDED USE TYPE OF WELL 4 <br /> INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation.— k <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - . �j <br /> DOMESTIC/PUBLIC ❑.ORIVEN - �� <br /> Gauge of Casing <br /> ❑ IRRIGATION X,�;RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �.� <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ---_ N.P. <br /> PUMP REPLACEMENT: State Work Dcne_G `-1,4- <br /> ­IMP REPAIR: ❑ State Work Done �0'' <br /> STRUCTION OF WELL: Well Diameter Approximate Depth til <br /> Describe Material and Procedure r <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 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 for which this C� <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will calf for a G o t Inspection prior to grouting and a final inspection. <br /> i <br /> Signed X Title: --� � �e.�..'�, _ Date:�_m <br /> (Draw Plot Plan on Reverse Sided) <br /> FOR DEPARTMENT USE ONLY ~ ,t <br /> PHASE t <br /> Application Accepted By. __ 1�• Date x <br /> Additional Comments: <br /> Phase 11 Grout Inspection —phaw III Final Inspection s <br /> inspection By Imp_ Date _ _ Inspection By Date _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 1 ❑ July t &Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> -- -- AMOUNT r <br /> FEE �. <br /> LESS <br /> PRORATION ,I <br /> PLUS <br /> PENALTY <br /> t <br /> OTHER <br /> OTHER. <br /> X733 �/r� <br /> r� <br /> Received by Date Receipt No. Permit No --wince Date Ma ed' Delivered a <br /> i <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.MAZELTON AVE.,A.O.Boy 2009 STOCKTON.CA 95201 <br />