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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> F ENVIRONMENTAL HEALTH PERMIT <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 JoaOgini Local Health District <br /> Exact Site Address 75-0 t~'f l✓t'{�lhJ;w < City/Town U <br /> Owner's Name p I010- TC-Ct L W. AU6 Phone l 3�► 0 <br /> Address 0 L M. City CA <br /> ' qc,-4. —ss�7 <br /> Contractor's Name �1.1}21�- UJ�LL Lf QutiPH�Yu� License# ��D eusines's Phone <br /> Contractor's Address 1•�Z C a' '� L' W y° `Emergency Phone i• :;' '' - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes V No ^' <br /> TYPE OF'WORK (CHECK): NEW WELL C%� -DEEPEN ❑ ' RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ ° F <br /> DISTANCE TO NEAREST: Septic Tank mo + Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 4 Property Line Private Domestic Well.—.Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_...___ -� <br /> 10 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing C <br /> ❑ DOMESTIC/PUBLIC I , DRIVEN x Gauge of Casing CL 140 Pitt' S <br /> ❑ IRRIGATIONS "t ❑ GRAVEL PACK' :Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Tf <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL " g Surface Seal Installed By: <br /> 7 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done } <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which 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 /> C tractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> p r it is issue , I shall em y perso s subject to workman's compen§ation laws of California." <br /> I I all for GrJyy11ut In tori prior a grouting and a final insp lion. �--- I <br /> Signed X Title: _ �`�rL� �-�`+' Date; <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - .. _.. <br /> � Application Accepted By t V "~�� Dated <br /> Additional Comments: ' <br /> as�Gro�tnspection ` L Phase III Fina Inspection <br /> Inspection B Dat r �3 Inspectiony ate ... —' <br /> ;. . ' �PJv +ti � PUU1- ,�gaw Cy,10 W S" <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT '❑ PER SITE -'El EACH� �❑ January-1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> -BILLING REMITTANCE $ <br /> BASE -' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE a) <br /> I LESS .: <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> '€ Received by Date Receipt No., - - Permit No. 'Isuanc Date _ Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo=2009 STOCKTON,CA 95201 <br />