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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> OFFICE USE: APPLICATION I��iaA� FoR <br /> (For Non-Transferable, Revocable,Suspendable) ?E3t*1 0 Iq <br /> - PUMP&WELL <br /> j ENVIRONMENTAL HEALTH PERMIT T TR� <br /> t r <br /> (COMPLETE IN TRIPLICATE) ��� Ja ��`F WATER QUALITY �p ' <br />! Appli.cationishereby made tothe San Joaquin Local Health District for aperr6ittoconstructand/brin�althernrorkherF <br /> Thisapplica4f�fii <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the-rules and regulations of the San Joaquin Local Di$t -c <br /> �. �� + 3 <br /> Exact Site Address 51_L0 g Ry.EF Arc k.731=;im City/Town 983 <br /> I I <br /> Owners Name _ "C'C]N�l1PA)IIANIS Phone 10A <br /> 11 1? �r1y E. S1A�}�11L)T City—BtLI]p�Qe # � <br /> Contractor's Name G u %jr, '1�LJrn�g 3R_1.f�B171`�t.1 License# �Q�j_t_ Business Phone�27-SSS$ <br /> Contractor's Address VI-1151A t.1.44UJY.�$� ED. Emergency Phone . <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �t/ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13"' PUMP REPAIR C3 <br /> REPLACEMENT❑ � s r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other t� <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br />} ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of+dell Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of:Weli.-Casing <br /> ,I <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br />} IRRIGATION ❑ GRAVEL PACK Depth of LGrout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout '�- <br /> ❑ DISPOSAL ❑ OTHER Other Information &._� U A <br /> ❑ GEOPHYSICAL Surface=Seal Installed By: •--� <br /> t <br /> PUMP INSTALLATION: Contractor GcDehr' - <br /> Type of Pump Sybm 1b1e H.P. <br /> PUMP REPLACEMENT: -State-Work-Done <br /> i <br /> PUMP REPAIR: ❑ State Work-Done- <br /> DESTRUCTION OF WELL: rWeII Diameter r� ' "` - App7ozimale Depth _� <br /> Describe Material and Procedure <br /> f I hereby certify that I have prepared this application and that the work will be doneyin accordance with San Joaquin County 4,-, <br /> I 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 performanceof the work for whichthispermit <br /> is issued, I shall not employ any person in such manner as to become subject td 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 isissu I I employ persons subject to workman's compensation laws of Calif6rhia-" <br /> i - <br /> I will call In ection prior to grouting and a final inspecti <br /> I Signed X Title: Date: <br /> I. (Draw Plot Plan on Reverseglide) ' <br /> i <br /> •-- -���_• <br /> --FOR DEPARTMENT.USE ONLY _ <br /> PHASE <br /> Dat <br /> Application Accepted B <br /> Additional Comments: Wf, d E <br /> Phase II Grout Inspection ase In F' I spect'on <br /> Inspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By la ry 31 ❑ July.1 &Received lay July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASER EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> k , PENALTY <br /> OTHER !i <br /> I OTHER75, <br /> I� <br /> I <br /> P Received by Date - Receipt N. <br /> Permit No. Issua ce Dat Mailed Delivered - <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />