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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR-OFFICE USE: . APPLICATION <br /> w (For Non-Transferable, Revocable, Suspendable) i <br /> PUMP &WrLL °r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ,a. WATER QUALITY <br /> Application is hereby made to the Sane' Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. l' <br /> Exact Site Address t._L-.14 Tr.VL j,!_� 1 �^'t + �^�a L•'��y City/Town -s/ c ck7-v <br /> Owner's Name Phone 0,ccJ— <br /> Address City <br /> Contraclor's Name _ � _ License fl Business Phone—s+-,-3 J ��- //�� t. <br /> Contractor's Address 3 CK'C-e,,0 ,1&J1 �}1�4,UA—�aLp Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on Filo With SJLHD? Yes✓ No j <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ OESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER @-- PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f, <br /> ❑ INDUSTRIAL �❑�CCABLE TOOL Na. of Well Excavation_ .7_ }' <br /> 11 ,�DOMESTIC/PRIVATE -DRILLED Dia. of Well Casing /� "f _ =+l' <br /> 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ :--_...,.. z ',J <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ` v <br /> Cif C <br /> ❑ CATHODIC P90TECTION ROTARY Type of Grout `Jt <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> d GE=OPHYSICAL ,,��,, _'J![1� s.� Sutrf Se I tali d y: <br /> PUMP INSTALLATION. U v ontractor a�U � _ <br /> Type of Pump _ KP, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work bone <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth /j- <br /> Describe Material and Procedure -1, 1� S ec <br /> uJ r <br /> LL <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin CountyKu <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. rh � <br /> Homeowner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this rmtt <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 for which this <br /> xg permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 e III for a Grout Ipectlon pr' r to grouting and a final insp ction. ` <br /> Signed X "J�.._.. wt C C?.•.rf <br /> Title: Date: f C <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ry1.1� <br /> Application Accepted By Date ���d <br /> F Additional Comments: XJ — <br /> l Phase 11 G mqt Inspection Phase III Final Inspection <br /> Inspection B L+ Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE 5 REMIT t <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> .� DATE DATE REMITTED AMOUNT <br /> L <br /> FEE l <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Datd Receipt No. Permit No, I Issua cel Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O.Box 2009 STOCKTON,CA 95201 <br />