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i Applications`Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApplication. <br /> FQR,.0.FFWE USE: I APPLICATION <br /> (For Nan-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT s <br /> a a>< uattTr <br /> (COMPLETE IN TRIPLICATE)-1q4 d')e $c-,4 ni� , n de 2-70 -0r <br /> Application is hereby made to the San Joaquin Local Health District fora permltto construct and/or install the work herein described.This application is <br /> E made in compliance with San Joaquin County Ordinance No. 1862 and the 110 rules and regulations of the San Joaquin Local Health District. <br /> i Exact Site Address rity/Town <br /> Phone ' <br /> Owner's Name i <br /> Address _ City <br /> i Contractor's Name License#19770ft-11 Business Phone <br /> Ij Contractor's Address ° L Zoe Emergency Phone <br /> r Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �~ No <br /> I TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION C] WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> f DISTANCE TO NEAREST: Sep tic Tank / Sewer Lines �e�d , Pit Privy <br /> Sewage Disposal-Field w. -Cesspool/See�14 page Pit <br /> i >i/ <br /> ~ Property Line Private f]omestlo VtifQll Public Domestic Well <br /> 'INTENDED USE„_ - ry �, YPE OF WELL � �+ s .� - <br /> t ❑ INDUSTRIAL I CABLE TOOL �� —Dia of Well Excavation, � `��' <br /> 0,,_,�IN h <br /> &l OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 0�X MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> kIRRIG <br /> ATION ❑ GRAVa PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout — e <br /> ❑ DISPOSAL ❑ 0THER,_:, Other Information <br /> ❑ GEOPHYSICAL i”- Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor 1� <br /> t 544{ Type of Pump H.P, tih <br /> PUMP REPLACEMENT: ❑ State Work Done 4 <br /> PUMP REPAIR: 11 State V�ork Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 <br /> I hereby certify that I11have prepareq.this application and that the work will be done in accordance with San JAj2 <br /> ty -ordinances, state laws and rules ancf,regujations ofthe.San_Joaquin Local.Health.District. - - .3.- <br /> Home owner or licensed agenl's signature certifies the following:QJ certifythat in the performance of the work for wit..,.,�•.,.isJSsued,.1 shallnot employ any person in such manner as to become;aubject to workman's compensation lawsa.", Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the worisf�,�permit'is ued,I shall employ persons subject to workman's compensation laws of California."II"for a Grout Insp 'tion prior to grouting and..a final inspection. �i Date � �1 <br /> E Signed X Title: l B.fJ <br /> (Draw Plot Plan on Reverse Side) !" <br /> �- ;.FOR DEPARTMENT-USE ONL-Y PHASE I <br /> -n ed 1 L <br /> Application Accepted By Date <br /> Adiitional Comments: �M <br /> /r tipe Il Grout inspection �� se III Final Inspection <br /> F Inspection By Date Inspection By Date 2 <br /> . I <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> • - BASEEXPLANATION DATE DATE REMITTED <br /> 11 AMOUNT <br /> FEE . I <br /> PRORATION <br /> PLUS I <br /> { PENALTY <br /> OTHER I! { <br /> OTHER <br /> r II b9 l b <br /> Received by Dale ^•- Receipt No. -. Permit No. lssuanc Dae Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES '1661 E.HAZELTON AVE.,P.O.Bar 2069 STOCKTON,CA 95261 <br /> II — <br />