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( IApplications Will Be Processed When Submitted Properly Completed. Be SureTosign IneAppncouvn. <br /> llA� y APPLICATION <br /> r FOR OF IGE USE: E <br /> f (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r;• - � '�� <br /> (COMPLETE 1N TRIPLICATE) Pa — hFe4�� 3' <br /> WATER QUALITY 6GS- X30--C3 ,� <br /> i Application is hereby made totheSan Joaquin Local Health District fora permit to construct and/or install the work herein described.This application isy- <br /> made in compliance t San Jo quin Count Ordinance No. 1862 and the rules and regulations of the San Jo o�n Local Health District. <br /> Aoll �h OY'L t�/�.I� City/Town <br /> t ' . Exact Site Address_ � ' <br /> I S . S r a7rNc rJ �S. �t�iTc�-t> iV[l�AR/p�o,Phone '9V.-` Z GOA <br /> Owner's Name <br /> Address L City <br /> Contractor's Name _ W License# Business Phone <br /> I Contractor's Address <br /> ` Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> ' TYPE OF WORK (CHECK): NEW WELL$ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> _ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> i REPLACEMENT❑ � L <br /> i 7U Sewer Lines 400 i Pit Privy <br /> ' DISTANCE TO NEAREST: Septic Tank <br /> Sewage Disposal Field d! Cesspool/Seepage Pit Other <br /> Property Line 40"' Private Domestic WeIA��_ Public Domestic Well <br /> I INTENDED USE TYPE OF WELL <br /> ' ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Welk Casing <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC �d <br /> 19 IRRIGATION �f GRAVEL PACK Depth of Grout Seal <br /> 1:1CATHODIC PROTECTION yix ROTARY Type of Grout <br /> 13 DISPOSAL ❑ OTHER Kt Se. Other Information <br /> 1 ❑ GEOPHYSICAL /� Surface Seal Installed By: <br /> PUMP INST LATION: c�ontractor 4 <br /> I J /I-`'"Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP-REPAIR: 7.7 ir/ ❑ State Work Done <br /> t DESTRUCTION OF WELL: j 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 /> i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, <br /> + i Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> iis issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> i Contractor's hiring o ub-c ractin nature certifies the following:"I certify that in the performance of the work for which this <br /> permit i issued, I s I loy persons bject to workman's compensation laws of California." <br /> I will c fa on for 10 gr uting and a final insp on. <br /> j Signed X <br /> Title- Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR PARTME T USE ONLY <br /> i PHASE I �a7lfo <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection a III Fina spection <br /> 111 Date Inspection By �' Date !o <br /> Inspection By — �e <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE! ❑ EACH ❑ January 1 &Received By January ❑ July t Received By July 31 <br /> j� _.. REMIT <br /> 1 - - BASE ICY BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION <br /> 1 D TE DATE REMITTED AMOUNT <br /> 1 <br /> FEE <br /> LESS $ <br /> 1 PRORATION <br /> PLUS <br /> PENALTY <br /> 4 OTHER <br /> 14 <br /> OTHER ; <br /> �2 <br /> 4 ,7 �'6 c�, d X71 <br /> Received by Da Receipt No. +� Permit No Issuance Date Mailetl Delivered <br /> - 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601-E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />