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A Il tW&MllIdeItdceWhen Submitted ProperlyCompleted. BeSureToSignThe-Application. <br /> FOR � <br /> _R OFFICE APPLICATION <br /> � <br /> (For Non-Transferable, Revocable,Suspendable) <br /> BAR 2 5 1980 PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT _ <br /> 07 <br /> (COMPLETE IN TRIP Ea� t���C���� �� WATER QUALITY . <br /> Application is hereby ma 6_0Jn90g ill'L'PJIHealthDistrictforapermittoconstructand/or install the work herein described.This application is (]j <br /> made in compliance with San Joaquin Count rdinane No. 6. and the rules and regulations of the San Joa in Local Health District. <br /> Exact Site Address _ Gity/Town <br /> Owner's Name Phone 7 �T - <br /> Address 47 IJ- 7A <br /> Contractor's Name License#3_132_vTa Business Phone_ i-Oz- 7 <br /> s Emer enc Phone <br /> Contractor's Address 9 Y <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 /> REPLACEMENT❑ 4 11 <br /> "�D1TA`<�Ci3 NEAR7=S f: -Septic Tank Sewer Lines Pit Privy - <br /> x i <br /> Sewage Disposal Field Cesspool/Seepage Pit Other F I <br /> Property Line"/Private Domestic Well Public Domestic Weil <br /> INTENDED USE TYPE OF WELL r� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 9 DRILLED Dia. of Well Casing <br /> -s <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION J9 GRAVEL PACK Depth of Grout Seal zh <br /> ❑ CATHODIC PROTECTION 19 ROTARY Type of Grout Xe �# <br /> F� <br /> ❑ DISPOSAL ❑ OTHER Other Information J <br /> ❑ GEOPHYSICAL �'/ Surface Seal Installed By: �1 <br /> PUMP INSTALL TION: Contractor /K CZ� 1' <br /> flQ 11Yc S �l� 04 lr,��t� Type of Pump �s.� H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: 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 /> 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 forwhich 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." I <br /> I Contractor's hiring or sub-co ratting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is iss ed, I shall y persons subject to workman's compensation laws of California." <br /> I will or a(a' Lit ct' or to grouting and a final inspe 'o r> <br /> Title. <br /> Date: <br /> Signed <br /> (Draw Plot Plan on Reverse Si e) <br /> I FO DEPART ENT USE ONLY <br /> PHASE <br /> Application Accepted By Date_3410 <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Fin Inspection rr <br />�. Inspection By Date Inspection By Date b' <br /> Cr <br /> k Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By 3anuary 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ` <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i Received by Date Receipt No, Permil No. 4 suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/ ERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />