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Applications Will Be Processed When Submitted Properly Completed. Be SareiTa Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) '-7LfQS Ad ��L_^4d 'WATER QUALITY 43 - 2cp—0 <br /> Application is hereby made to the San Joaquin Local Hoalth 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 rule and regulations of the San JO a uin Loca Health District. <br /> Exact Site Address °iJe'd�"Sr,�� 4 .14-`J�a" hei"a^r� 6'.JIP1,tm City/Town <br /> Owner's Name u`6ill - t Phone <br /> Address City. 0"A&1 , <br /> Contractor's Name *17W ?' :''iLicense# if-17 Business Phone •. 44L -74-74 x <br /> Contractor's Address 90 aL' R.€ + Emergency Phone y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No r <br /> TYPE OF WORK (CHECK)71-- -NEW WELL❑- DEEPEN El - -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 x Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL i <br /> ❑ INDUSTRIAL _t i. ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _. a <br /> ❑ CATHODIC PROTECTION 11.ROTARY Type of Grout i <br /> ❑ DISPOSAL ❑ OTHER Other Informaliori <br /> ❑ GEOPHYSICAL, Surface Seal Installed By: f r q <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Wo a _C7..) /,41' { <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done <br /> DESTRUCTION OF WELL: 'Well Diameter' Approximate Depth S i <br /> Describe Material and Procedure `. -0C ',I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Ce <br /> Homeowner or licensed agent's signature certifles 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 tor which this. <br /> permit is issued,-1 shall employ persons subject to workman's compensation laws of California." ; <br /> I Will call for a Grout Insp ctio prior to routing a d a final inspection. - <br /> Signed �� { Title: _ 1{�f' Date: '� <br /> (Draw of Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p' <br /> Application Accepted By /�' - Date /-► Z �- <br /> Additional Comments: <br /> Phase II Grout Inspection ' Ph a III Final Inspection <br /> .Inspection By Date . Inspection.By Date 7' <br /> 'Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 '+! <br /> REMIT <br /> BASE EXPLANATION- BILLING REMITTANCE - $ AMOUNTDUE CHECKED <br /> DATE DA REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 22 ' <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> l OTHER <br /> 1 <br /> Received by w Date Receipt No Permit No. Isru -_Date Mailed Delivered; <br />�`- <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />