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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T <br /> FOR;QFFICE USE: APPLICATION <br /> < (For Non-Transferable,Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No, 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address � -?- ! By/4 � Z_AA)�_= City/Town Z_ :)IL,; <br /> Owner's Name1411--1 Phone -S-77 G!1-5t 1 <br /> Address 2_ c) — City. L <br /> Contractor's Name QT(�Uli- *`y��� i��r„� License# - 3 11 Business Phon s3 <br /> Contractor's Address 5z CC112Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL � DEEPEN ❑ RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENTK OTHER ❑ PUMPINSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> Septic <br /> DISTANCE TO NEAREST: "c Tank .r q <br /> P Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit. <br /> Other . <br /> Property P YLine—._Is.._Private Domestic Well Public Domestic Wel! 6c)' 7`rh.R� <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑.; d <br /> CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN <br /> Gauge of Oasing <br /> ❑ IRRIGATION= gGRAVEL PACK Depth of Grout Seal el�C� <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout f" , <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. O <br /> PUMP REPLACEMENT: ❑ State Work Done_ <br /> P.�MP-REP111`n ❑ State Work Done_ � <br /> ESTRUCTION OF WELL: Well Diameter-^ Z� � <br /> (( ' Approximate Depth <br /> Describe Material.and,Pc Cedure f <br /> 1 <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ill tali for a Grout In a tion prior to ting and a final inspection. <br /> Signed X Title: _45s)S1._(, DIf..�J r = L�J1�- Date: J • <br /> (D aw Plot Plan on Reverse Side) <br /> FOR PARTMENT-USE ONLY <br /> PHASEI <br /> Application Accepte y Date° . <br /> Additional Comme s: <br /> Phase 11 Grout Inspection Phase II Final` Ipection <br /> Inspection By ate sp_ 4 1g ction B " �7 <br /> Fee Is Due: El ANNUALLY El PER UNIT El PER`SITE El EACH Ely Januar � � <br /> &Received By January 31 ❑ July 1 &Received By July 31 I• <br /> BILLING REMITTANCE REMfT <br /> BASE EXPLANATION DATE $ AMOUNT DUE CHECKED <br /> DATE REMITTEp AMOUNT <br /> FEE B- � _Mow__ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> A <br /> Do- <br /> Received by DateReceipt No. Permit No Is uance bafe Mailed Delivered ..1. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTo"CA 15111 <br />