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Applications Will'Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) S <br /> I <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the Sari Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> made in compliance with uin C rl-y Oo ance fq„186 an"e roles yd replations of the San Joaquin Local Health District. <br /> Exact Site Address �'ia /�'' �f �� i, /�V� GFS ity/Town Ei�E'/ll 1 <br /> 4�MEti¢<ils�a�/ lv�s SS,S <br /> Owner's Name AJ lT�C/C� Phone }" i <br /> Address les ll adln!A/1[LC-- 72T.? City ` <br /> Contractor's Name icense# -3-7-AM_ Business Phone e, , <br /> Contractor's Address QaC 3 f'!t?/!__- - Emergency Phone —7 <br /> Is Certificate of Workman's Compensation Insurance on File With-SJLHD? Yes Lr No <br /> TYPE OF WORK (CHECK): NEW�WELLIx DEEPEN ❑ RECONDITION 13DESTRUCTION13 f <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ `4 <br /> REPLACEMENT❑ Apt <br /> DISTANCE TO NEAREST: Septic Tank /Ste` Sewer Lines © f Pit Privy <br /> .i <br /> Sewage Disposal Field Cesspool/Seepage Pit 'ter Other <br /> Property Line SO Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �} <br /> ❑ INDUSTRIAL 9 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTiC/PUBLIC i ❑ DRIVEN Gauge of Casing /o <br /> IRRIGATION r ❑ GRAVEL PACK Depth of Grout Seal 5- <br /> CATHODIC PROTECTION ❑,ROTARY Type of Grout 52 5,04,_-' Ct="d7V7— Ao�77— <br /> ❑ DISPOSAL ❑ OTHER Other Information a4 <br /> ❑ GEOPHYSICAL i- Surface Seal Installed By: T`-! <br /> PUMP INSTALLATION: Contractor 45711oosllgnlv V&ZU 1614 dT <br /> Type of PumpH.P. Jam " <br /> PUMP REPLACEMENT: i ❑ State Work Done N ° <br /> PUMP REPAIR: h ❑ State Work Done <br /> DESTRUCTION OF WELL: ° Well Diameter Approximate Depth ( ; <br /> Describe Material and Procedure ' <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r <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." r <br /> Contractor's hiring or sul L 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 /> I 2�ut Inspecton ri to grouting and a final inspection.Signed Xli Title: <br /> �l Date: <br /> l (Draw Plot Plan on Reverse Side) <br /> I� <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By. I Date <br /> i <br /> Additional Comments- <br /> 011 <br /> omments: l <br /> haleA�outpection hale I Inspectio ` x <br /> Inspection By Gid JDate _—Inspection By �l r <br /> 1 <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 /> y! BILLING REMITTANCE $ <br /> BASE �! EXPLANATION - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED Ur AiviOUNT <br /> FEE <br /> LESS' �j } <br /> PRORATION t <br /> PLUS <br /> PENALTY I� <br /> OTHER <br /> OTHER Ip <br /> Received by. Date �� Receipt No. Permit'No. I scan a Date Mailed Delivered rr <br /> APPLICANT—RETURN ALL COPIES„TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,P.D.Box 2009 STOCKTON,CA 95201 <br />