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Applications Will Be Processed When Submitted Properly Completed. BeSureTOSign <br /> FOR OFFICE USE: APPLICATION <br /> ..r 4 (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> PLETE IN PLICATE) <br /> (COMTRICOMalionislRI made to the San Joaquin Local HealthDistrictforapermittoconstruct and/or install the work herein described,This application is <br /> Applicmade in compliance- ith San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact_ Site Address <br /> /GR ,�4Afrit' r/,,..'-, ri+t City/Town <br /> Phone <br /> Owner's Name �' A-0 <br /> Address `— �4ej� <br /> City C ' le <br /> Contractor's Name w tfLicense# ^� 7 Business Ph r C 3 „ <br /> Contractor's Address _ di Emergency Phone ..- <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes e__ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIDN❑ <br /> WELL CHLORINATION ElWELL ABANDONMENT 11OTHER 11PUMP INSTALLATION C1PUMP REPAIR ^^ <br /> 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 ' <br /> E-1 CABLE TOOL 11 <br /> E] INDUSTRIAL Dia. of Well Excavation <br /> 11 DRILLED Dia. of Well Casing <br /> © DOMESTIC/PRIVATE �I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing p <br /> 2�'TMRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout v <br /> �❑ DISPOSAL <br /> C3OTHER Other Information <br />�- <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P' q <br /> C" PUMP REPLACEMENT: ❑ State Work Done fI <br /> PUMP REPAIR: ❑ State Work Done -A W4 <br /> . i DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> r <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 Joa1.quin County <br /> a 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 i <br /> i is issued. I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> l 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." <br /> I will call for a Gyf1nspection pri to grouting and a final inspecti n. <br /> Signed X <br /> +may Title: d Date: 7 � — <br /> {Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i //� 5 ] � <br /> G Date��� <br /> j Application Accepted By <br /> Additional Comments: <br /> ' Phase 11 Grout Inspection Plias All 'anal In coon/ <br /> Inspection By <br /> Date inspection By ate <br /> �• Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION DATE <br /> REMITTANCE $ AMOUNT DUE CHECKED •_,,,:' <br /> DATE DATE REMITTED AMOUNT <br /> qt FEE S <br /> LESS = w <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I <br /> E OTHER <br /> # OTHER <br /> `7 <br /> - Received 6t' Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 I STOCKTOTij;C1 9520 <br /> f <br />