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Applications Will Be Processed When Submitted Properly Complet SUr#,NJO ilgrr"TneAPPTICa�IpT.I <br /> �ailiOff ICE USE: APPLICATION a� <br /> z 1 (For Non-Transferable, Revocable, Sus le}FEB 1 cs 1980 PUMP&WE(-1- t;T <br /> ENVIRONMENTAL H ATH PERMIT - <br /> /✓r QuA" LI Y SAN JaA IJS STRIU <br /> (COMPLETE IN TRIPLICATE) � � /^ I# f�t�reN <br /> Application is hereby madetoth an Joaquin 1- ca�HealthDistrictforapermittoconstructand/ori ork ereindescribed.Thisapp <br /> licationis <br /> made in compliance with San oaquin County Ordinance No. 1862 and the rul S and regulations of the San Joaquin Local Health District. <br /> Exact Site Address � cQ ' �' City/Town <br /> f /¢� f <br /> U. " N 4Gtcitn Phone - 3 <br /> Owner's Name _: � I„Q6i'/a- <br /> Address ?OL. p�¢j tf P15_�_ox 121L <br /> Contractor's Name +� <br /> - License#�1s3�_ Business Phone <br /> Contractor's Address -T' W Al ST�1/'p"� 9'S-469 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �_< No <br /> TYPE OF WORT( (CHECK): NEW WELk. A DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 19 PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> r v Pri <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines `' Pit Y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property tine Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELLe - ` <br /> ❑ INDUSTRIAL 11 CABLE TOOL Dia..of Well Excavation. <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing A <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing !, <br /> I ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Al i S <br /> Type of Pump Se-1k re4 H.P. 1 �Y <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 /> f 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> k is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> C <br /> 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 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> ". .'Title: � u .Psr�� Y �+� Date: <br /> Signed X` �f/�,1 _� <br /> (Draw Plot Plan on Reverse Side) 1 <br /> F EPA MENT S€ONLY 1 _ <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: ' , <br /> Phase Il Grout Inspection PI e I Final I ection <br /> Inspection By i Date Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 r July 1 &Received ByEMI <br /> eceiv dByI July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY - - <br /> OTHER <br /> OTHER <br /> Permit No. - Issuance Date Maiied Deiivered <br /> Received by Rafe Receipt Na <br /> F. ..x.t. ,APPLICANT=.RETURN ALL COPIES TO:' `ENVIRONMENTAL HEALTH PERMIT/SERVICE 1607 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 952D1 <br />