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Applications Will Bei Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,fOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) 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`andlthe rules andregulations of the San Joaquin Local Health Distr <br /> Exact Site Address 6901 City/Town T,i ndpir'" ict. <br /> Owner's Name Albert Metzler. Phone ►' y <br /> oh <br /> Address g _'.N•. Wall __ '< City ­Linden, <br /> City <br /> Contractor's Name Clark Wel'l-&.2E ul meat. t`License#371,560= Business Phone S <br /> Contractor's Address 2U2 E:.f-'Chatter ,Way 1, -`Emergericy Phone �t. " tl;r= NV, a # <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK)-7 —NEW WELLW- DEEPEN ❑ `RECONDITION❑' pDESTRtJCTIOfV❑ <br /> WELL CHLORINATION C1- r WELL,ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 41_ tar r _ ` ' A <br /> DISTANCE TO NEAREST: Septic Tank +100' Sewer Lions old' A �'i�e; Privy <br /> i.7 Sewage Disposal Field Cesspool/Seepage Pit :.Other - <br /> �*sf ►Y Property Line Private Domestic Well Public Domestic Well <br /> F INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL x <br /> x" M CABLE TOOL ;, Dia. of Well Excavation 14" <br /> ❑ ADOMESTIC/PRIVATE r, ❑ DRILLED" "'.,� Dia. of Well Casing 1411 I <br /> ❑ DOMESTIC/PUBLIC ❑ D—RI VEN <br /> Gauge of Casing 50 Steel <br /> 91 IRRIGATION -, 4 - . ❑,.GRAVEL PACK Depth of Grout Seal N <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER # s Other Information <br /> ❑ GEOPHYSICAL` Surface Seal Installed By:, <br /> PUMP INSTALLATION: Contractor <br /> y t Type of Pump — _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ <br /> PUMP REPAIR: ❑ State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> O <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 Heaith 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 Z—& t <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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued. I shall employ persons subject to wdrkman's compensation laws of California." <br /> - I V4.sall.for a Grout I t' lora g u#ing and a final inspection. E y <br /> Signed X Title:. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> v FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> E' <br /> r # { <br /> Application Accepted.By- Date ' <br /> Additional Comments: <br /> t Phase ll Grout Inspection 4 ' <br /> Phase III Final Inspection <br /> ;Inspection By :Date . Inspection By Date <br /> , • <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' -" ❑ PER SITE ❑ EACH ❑ January-1 &Received By January 31 ❑'July 1 &Received By July 31 <br /> 1 ' BILLING r REMITTANCE REMIT - <br /> BASE EXPLANATION $ AIMOUNT OUE CHECKED <br /> 1 DATE DATE REMITTED <br /> AMOUNT ' <br /> FEE <br /> BLESS - <br /> PRORATION <br /> PLUS„ <br /> PENALTY ~'•,r ' <br /> OTHER - <br /> }. r , <br /> OTHER <br /> WN <br /> Received by -- -- DataReceipt No. Permit No. <br /> Ishuance Date I Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVrCES 1601 E.HAZELTON AVE.,P,O.Box 2009 STOCKTON,CA 95201, ' <br /> I A <br />