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. ... <br /> F Applications Will Be Processed When Submitted ProperlyI <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> w_ ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) j ('77 j F-F rit.L1G �Lj <br /> WATER QUALITY 1,24-- Cev—0—r <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San JoaqAin County m <br /> Or ance No. 1862 and the rules and regulations of the San joaquin Local N alth District. <br /> Exact Site Address N <br /> I, LO v�5c- ve- - llfow4 roD City/Town <br /> �st � <br /> C/LU L P/c <br /> N Phone �r� ' �/ <br /> Owner's Name 1 <br /> City _ <br /> I <br /> Address779 O. <br /> L 4t**t <br /> ense# Business Phone <br /> Contractor's Name _ <br /> Contractor's Address } Emergency Phone <br /> - Is Certificate of Workman's Compensat on Insurance on File With SJLHD? Yes NO <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> E WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR© <br /> REPLACEMENT❑ <br /> I DISTANCE TO NEAREST: Septic Tank <br /> 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 6 0r <br /> El INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation A- <br /> C1 DOMESTIC/PRIVATE JA DRILLED Dia. of W, Casing <br /> rp <br /> ❑-DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge Of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 11ROTARY Type of Grout _�/ �Li✓]FN T" <br /> ❑ DISPOSAL ❑ OTHER Other Information �^ 6 <br /> A GEeFH"FCAL 4,C_0-1-c- HJV(CAL Surface Seal Installed By: <br /> f PUMP INSTALLATION: Contractor <br /> Type Of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: El State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 /> 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 /> Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> l will call for a Grout Inspection prigr to grouting and a final inspection. <br /> V <br /> S Title: <br /> Date: . PC <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> �! �� Date <br /> Accepted By <br /> Comments: <br /> lli F',5p[ Inspection <br /> Phase II Grout Inspection hase <br /> Inspection By <br /> Date Inspection / Date <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBy July 31 <br /> ZE <br /> ExPLANATION BILLING REMITTANCE $ AMOUNT BUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> f <br /> �- G�L <br /> 31a a <br /> Date Receipt No. Permit No l Suanc Date Mailed Delivered <br /> Received by = _ _ <br /> APPLICANT—RETURN A_LL COPIES TO: ENYIRON�NTAL HEALTH PERMIT/SERVICES "1601 E.HAZELTONAYE,P.O.Box 2009 STOCKTDN,CA 9520 <br /> It <br />