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t -iApplications Will Be Processed When Submitted Properlycompiezea. <br /> ola.oFIce USE: APPLICATION <br /> r (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) w <br /> Application is herby made to the San Joaquin Local Health District for permit construct and/or install the work.herein described.This app::,. <br /> made in compliance with San Joaquin County O Bina ce No. 1862 and t e ules and regulations of the San Joaquin Local Health District. •+te d' <br /> -77 City/Town <br /> Exact Site Address Q <br /> L 1A) Phone 6 <br /> Owner's Name City m <br /> Address <br /> AL i License#�� Business Phone r, <br /> k Contractor's Name �o�� ✓^h AjBnj <br /> p etC � �}C�i mP4Emergency Phone = <br /> Contractor's Address o Nom <br /> ;. Is Certificate ofCTION❑ <br /> .Workman's Compensation Ins rance on File With SJLHD. Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUPUMP REPAIR❑ <br /> -- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION <br /> # REPLACEMENT❑ s �� �� �/e fUQ�I�� <br /> t <br /> DISTANCE TO NEAREST: Septic Tank �� Sewer Lines h9_5?"r— - Pit P1i <br /> �f ;010 Other <br /> � Sewage Disposal Field /UO AJ4--- Gess ool/seepage Pit <br /> Property Line Private Domestic Well; OW -Public domestic Well w_� <br /> INTENDED USE <br /> ' TYPE OF WELL <br /> CABLE TOOL Dia. of Well Excavation <br /> ❑ NDUSTRIAL <br /> DOMESTIC/PRIVATE 11DRILLED pia. of Well Casing � <br /> i ❑ DRIVEN Gauge of Casin <br /> ❑ DOMESTIO/PUBLIC -. <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout�Sea�l / <br /> 11 CATHODIC PROTECTION ❑,-ROTARY- Type of Grout <br /> { ❑ DISPOSAL <br /> 11 OTHER- Other Information <br /> 13 GEOPHYSICAL Su face Seal,Installed By: <br /> PUMP INSTALLATION: GontracI 4C <br /> tor <br /> L <br /> r r <br /> H.P. <br /> Type of Pump <br /> � <br /> ' 11State Work Done <br /> PUMP REPLACEMENT: <br /> PUMP REPAIR: ❑ State Work Done <br /> s Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter - <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit L <br /> EE4 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> q y`. <br /> i I wti call for a Grout Ins c�tio�n prior to grouting <br /> ®and a final inspection. f <br /> '� .. � ��1 �L Title: �� fiZ.a. �� Date: _f <br /> Signed X" (Draw Plot Plan on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> FAdditional <br /> �� CO) Date <br /> Accepted By <br /> iomments: 11 Groui Inspection � hash F al inspectionon By <br /> Date Inspection By to <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE El EACH ❑ January 1 &Received By January 31 [J JuVy 1 &Recely REMITBy uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASS EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> f ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by �':� 1601 E.HAZELTON AVE.,P.o.-i 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />