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ApplicationsWill Be Processed When Submitted Properly Completed. Sure To Sign The Application. <br /> }. FOR OFFICE USE: APPLICATION- <br /> 0 <br /> (For Non-Transferal;'} ,-Revoabl <br /> e,5uspendabfe) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE} i <br /> 7� ft u+.+s TER QUALITY <br /> Application is hereby madeto the San <br /> quin Local Health Districtfo-rF'a permitto construct and/orinstall thework herein described.This application is <br /> made incompliance with San Joaquin County,Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health Di trict. ; <br /> Exact Site Address LD �, .�G <br />` T �7 ) � / _ /J City/Town .—O <br /> 1 Owner's Name 04e/ci[sc •ZGltc f Gr-f' �j ���� i <br /> Address p IF Phone <br /> I Contractor's Name i City c ry i <br /> G�Gr't °��"� 9�License## � Business Phone <br /> Contractor's Address �$"Z,5 �,/17cjr��;,•S^ merg <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHDYes Phone <br /> ' <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11RECONDIYes No <br /> TION❑ DESTRUCTION❑ <br /> WELL.CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER, PUMP INSTALLATION L <br />' ❑ �! PUMP REPAIR❑ <br /> REPLACEMENT ~� <br /> DISTANCE TO NEAREST: . Septic Tank AJ 1A Sewer LinesPi <br /> A✓11 <br /> t Privy I <br /> Sewage Disposal Field /f Cesspool/Seepage Pit N1/}- � <br /> Property Line Zo Other <br /> P Y Private Domestic Well i$/ - Public Domestic Well <br /> INTENDED USE � TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL !� <br /> El r�� Dia. of Well Excavation <br /> l�-�-DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION Gauge of Casing A/ /.} <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 11DISPOSAL ❑ OTHER Type of Grout �! <br /> ® G �^ � Other Information <br /> �� �F}�t`Lsrilu✓� <br /> PUMP INSTALLATION: Contractor Surface Seal Installed By: <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> proximate Depth I <br /> Describe Material and Procedur$ <br /> 1 herebyrtifc� y that I have prepared this application and that the wo will be one in accordance h San Joaquin <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. County <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which 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." <br /> permit is issued, I shall employ persons subject to workman's compensation <br /> Contractor's hiring or sup-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> laws of California." <br /> dA7 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X � �[- srfc d[.�.� PAI C- <br /> �•r7 f (Draw Plat Plan on Reverse Side) �� Dale: l rZ) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Application Accepted By ,f <br /> Additional Comments: ;( Date <br /> I <br /> Phase It Grout Inspection <br /> Inspection By Phase III Final Inspection 3 <br /> Date nsp ron By <br /> L C.,• ✓``LJ�-� "�h Ql CtI Date <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH <br /> January 1 R ceived By January 31 ❑ July t &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATIONL <br /> PLUS y <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> L/4:7 _ a <br /> Received by Date - Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Mailed Delivered - - <br /> -'-* r 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201 <br />