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APPllcafloria WTII tie r°rbc5'ffTL 17lrall 5U,Ji,in,EU r UjR'1 y -urippirl JE, au iv i.. mg,I I.raAplam:,TTTUT. <br /> FOR OFFICE us€" APPLICATION. <br /> ,P•- For Non-Transferable, Revocable, Suspendable <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) - <br /> WATER QUALITY- -'r, <br /> Application is hereby made to the San Joaquin Local:Health District fora permit to construct and/or install the work herein described.This application is <br /> in <br /> made in compliance with San JoaquCounty Ordinance[No. 1862 angxthe rules and regulations of the San Joaquin Local Health District. <br /> Exact Site AddressClty/Town �'-- <br /> Owner's NameIj-C�fNL �IL -c-'`tea-!, PF�one . 15(L-C: <br /> Address (-Ll v ."C,E.. (� City <br /> Contractor's Name5�Z�CeZ:t- License,N'�3_ (]_� Business Phone <br /> 1— <br /> Contractor's Address _,leLCA—ILb -7 �-�— Emergency Phone �- <br /> Is Certificate of Workman's Compensation Insurance on Fil With SJLHD? , Yes _.L No <br /> TYPE OF WORK (CHECK): NEW WELL❑ .DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑1___P`UMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank — Sewer Lines _ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other Y <br /> Property Line Private Domestic Well _ Public Domestic Well <br /> INTENDED USE - TYPE OF WELL - <br /> ❑ IND STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> Ll IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. V ' � -' <br /> Type of Pump _ ---- H.P._ <br /> PUMP REPLACEMENT: 13State 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 1 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 thework 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 /> 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 /> 1 will It for a Grout Inspection prior to grouting and a final Inspection. <br /> Signed. _ �, Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By - Date .2�cz <br /> Additional Comments: -- <br /> - Phase II Grout Inspection - y �1�Ph� e III Finlont�� <br /> Inspection By Date __. Inspection B yry -�9-/_ * te : , �/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Cl Januery 18 Received By January 91 ❑ July 18 Received By July 71 <br /> tB <br /> _ .—___ . . REMIT <br /> ASE EXPLANATION BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �LESSPRORATPLUS <br /> PFNAIT <br /> OTHER <br /> OTHER <br /> 'F 33 12151 az" <br /> Received by Dale 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 STOCKTON,CA 95201 <br />