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Applications Will Be Processed Whe_ .:ut5m;Ated Properly Completed. Be Sure To igP 7Wpplication. Lui <br /> FOR OFFICE USE: APPLICATION CC �{ <br /> 4 (For Non-Transferable, Revocable, Suspendable) DE i ���� <br /> w PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT SAN .l()AQ UIN LOCA1� . <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYHEALTH DISTRICT i <br />' Application is hereby made totheSan.Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqui CountY Ordinance No. 1862 and the rules and regulations of the Sa Joaquin Local Health District. <br /> Exact Site Address /�� / .LAS, "00cJ1.4 {��. City/Town 6 02 1 9S330 <br /> Owner's Name _AG K. vk Phone -s- —2 92 <br /> Address �r7- -1 , d �i�+�t City 9330 <br /> Contractor's Name � CT-j--QC. License Business Phone eq --' <br /> Contractor's Address Ct.,� 74�fi �1'Ir¢ +`�9� gS�3�Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1--" No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> i 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 G,' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing (� <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ?� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By; ids <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter A proxim',ate Depth <br /> Describe Mate.'al and ProcedureA� <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 /> i <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit r <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." �� a 0"A( +BO? <br /> 1wit ll for a G. inspection prior 10 grouting and a final inspecti <br /> Signed X Title: Dale: /---/Cr�72 <br /> (Draw Plot Plan on ReveYse Side) <br /> F R D ARTME T USE ONLY <br /> PHASE O <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phos Il Final Inspection <br /> Inspection By Date Inspection By Date ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 12 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br />' BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Datd Receipt No.. Permit No. Issuance date Mailed Delivered 03 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i <br /> 6 <br />