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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign TheApplication. <br />"4 4. APPLICATION <br /> [FOR OFFICE USE: <br /> (For Non-Transferable,Revocable;Suspendable) / PUMP&WELL , <br /> ENVIRONMENTAL. HEALTH.PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct anal/or install the work herein described.This application is <br /> made in compliance with San Joaquin�ounty Ordinance No. 1862 and the rules and regulations of the San Jo qu' _Local Health District. <br /> Exact Site Address <br /> S [_� City/Town <br /> Phone Y r� <br /> Owner's Name City % - a'C <br /> Address �e �/`]�- <br /> L. f L . Business Phone_ <br /> Contractor's Namice nse# <br /> °���.'��^"� � P ��Azse0 <br /> Emergency Phone <br /> 34 <br /> Contractor's Address F` 1 <br /> No <br /> Is Certificate of Workman's Compensation In on File With SJLHb? Yes�� <br /> TYPE OF WORK (CHECK): NEW WELL0_DEEPEN 11RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER 13 PUMP INSTALLATION PUi1AP REPAIR 13 <br /> REPLACEMENT❑ f r <br /> DISTANCE TO NEAREST: Septic Tank <br /> aFieldt�'(!7�. <br /> Seer Lines . 49 Pit Privy <br /> Sewage DisposCesspool/Seepage Pit/10r)�— Other <br /> Property Line!_4 Private Domestic Well �. Public Domestic Well <br /> INTENDED USE TYPE OF WELL h <br /> ❑� INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> "DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> L <br /> 11DOMESTIC/PUBLIC <br /> 1:1DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5- <br /> CATHODIC PROTEGTION OTARY Type of Grout <br /> ❑ <br /> ❑ DISPOSAL 13 OTHER Other Information �� <br /> 13 GEOPHYSICAL Surface Seal Installed By: ' <br /> GontractD � � r i <br /> PUMP INSTALLATION: H.P. <br /> Type of Pump <br /> -PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r „ <br /> I Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> V" <br /> Describe Material and Procedure _ <br /> I hereby certify that I have prepared this application and that the work will be done inL 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, l 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 <br /> ermit is issued, I shall employ persons subject'to workman's compensation laws of California <br /> I call for a Gr t I to prior to grouting and a final inspection. f <br /> Title: Date: <br /> Sig <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> FAdditional <br /> a_ - 5-Ia- <br /> ASE 1 Dateplication Accepted By <br /> Comments: <br /> i al Inspection <br /> e 111 out Inspection as 1! <br /> III Z <br /> Inspection By % `" Date. _ ��jInspectioBy n.By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT', ❑ PER SITE ❑ EACH ❑,January 1 &Received By January 31 ❑ July 1 &ReceiveR�EMITuiy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1" d V (Q ` <br /> Received y <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivgred <br /> 1641 E.HAZELTON AVE.,P.O.8aM 24D9 STDCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. y <br />