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--► Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: J .,� APPLICATION <br /> ti f <br /> (For Non-Transferable, Revocable, Suspendable) ;' <br /> '' =' F PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> E (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and t rules and regulations of the San lfzquin Local Health District. <br />' Exact Site Address Gity/� [�1/ i FF ` <br /> Owner's Name pn !Q <br /> Address r City ^"" <br /> Contractor's Name License#,277¢�f/ Business Phone <br /> Contractor's Address A / . Emergency Phone <br /> Is Certificate of Workman's Compensation Ia on Fil ith SJLHD? Yes Zl No <br /> naura <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONM— <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION C. - PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank le2I2 Sewer Lines 420. Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line r Private Domestic Weil: Public Domestic Well <br /> INTENDED USE ,r, TPE <br /> pF WELL '� J <br /> ,❑-, liPPUSTRIAL - -� -•.�.-U;k1 ABL-ABLDia. of Well Excavation <br /> RDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION c ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 1! <br /> ❑ DISPOSAL r c ❑ OTHER 4 Other Information <br /> ❑ GEOPHYSICAL rface Seal Installed By: <br /> PUMP INS LLA t IONContractor ,� I <br /> Type of Pump I.S4z, <br /> H.P. <br /> PUMP REPLACEMENT:_ 11State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF°WELL: Well Diameter a ' proximate Depth <br /> Describe Material and Procedure <br /> 957 <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 J"oaquin'Local Health District. <br /> Home$'caner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit - 1 <br /> is issued, 1-shall not employ any person in such-manner as to become subject to workman's compensation laws of(California." <br /> Contractor'B 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."t: a <br /> I will �II fora Grout I ctio prior to grouting and a final inspection. <br /> r <br /> Signed X Title: ��� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> Application.Accepted By <br /> Date <br /> Additional Comments: <br /> .. <br /> le 11 rPut lnspectl.n=g Y- Pha§e III`Final Inspection, <br /> Inspection B_y_ - E~ rl a I spec 'o -By s�3�1 Date <br /> rte^!• - <br /> Fee Is Due:`❑' NUALLv �w PER UNIT ❑,PER SITE ❑ EACH ❑ Janu ry &Received By January 31 ❑ July 1 &Received By July 31 <br /> i;.,_,- 1 BILLhNG' REMITT.ANCL $. REMIT <br /> 5 BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE_ 'l DATE REMITTED <br /> AMOUNT"- <br /> 0-0 <br /> FEE <br /> LESS r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER' <br /> I 3 <br /> OTHER s t <br /> t <br /> Received by Date Receipt No. Permit No. I Issuaric'e Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />