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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabie) / <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 Ordinance No. 1862 and the rules and regulations of the San Joaquin Lo1 nct. <br /> Exact Site Address L!67 A A-MA9 Ai P7V" -0264 WF-r_0 City/Town ��dtTA QQ — <br /> Owner's Name .UG Phone� L <br /> Address S a KAAWAV JW City -CLL <br /> Contractor's Name GA)W47F-P Died LL IR3 rn License# < 2J 21-2 Business Phone__�� <br /> Contractor's Address _-SILeOy 7IE4OCK Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No <br /> TYPE OF WORK (CHECK): NEW WELL 14 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank- Sewer Lines _ Pit Privy <br /> Sewage Disposal Field_2.OQ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL y, <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> .X'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing /1111 <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> TL <br /> ❑ IRRIGATION P GRAVEL PACK Depth of Grout Seal 7 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout i1 <br /> ❑ DISPOSAL ❑ OTHER Other Information rn <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 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 s <br /> Contractor's hiring or subcontracting signature certifies the following:"I certify that in the performance of the work forwhichtl is <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I,wwiill call fo/pa Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: 1.9 p-rf'l <br /> (Draw Plot Plan on Reverse Side) <br /> F R-DEEPARTMENT USE ONLY <br /> PHASE I �;9/,-_ <br /> Application Accepted By Date <br /> Additional Comments: <br /> ,,y,�,P,�s��Qj�1�I`�1 `G�r��o�ru�t Impaction G Phase III Final Inspection <br /> Inspection By Date <br /> O �/ Inspection By �� Date <br /> Fee Is Due: ❑ ANNUALLY 9®❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> DO <br /> FEE AH l 3 L43-- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No. Iss ance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16111 E.HAZELTON AVE„P.O.Boa 2000 STOCKTON,CA 95201 <br />