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AOpk,andris will dePrbcessed When Submitted Properly Completed. Be SureTo Sign The Application. <br /> OR OFFICE USE: APPLICATION I (-0/ y) <br /> Non-Transferable,Revocable, Suspendable) �? <br /> ENVIRONMENTAL HEALTH PERMIT PUMP/&WELL <br /> pp � //// / V <br /> (COMPLETE INT PLICATE) 7D,t/F,P/06E T� WATER QUALITY Application is heret¢made to the San Joaqui n Local Health District fora permit 10 construct and/or install the work herein described.This a plication is <br /> made in compliance with Sari Joa ui County Ordinanlc8�lN�o. 1862 and the rules and regul i IT o1 ih aD Joaquin Local Health Dis ict. <br /> Exact Site Address ,�J�/nL�\�Z [,1A1'1 .'757J� <br /> Owner's Name (. � � PhOne _ 73( —OS/?Z- <br /> Address - city <br /> Contractors Name J11� J. License If nXOp/.3 Business Phone <br /> Contractor's Address _ Emergency Phone <br /> Is Certificate of Workman's Compensation nsurance on File With SJLHD7 Yes X ' No ��^•�,, <br /> TYPE OF WORK (CHECK): NEW I' ELL, . DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ W <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank TJ_00 "Sewer Lines Pit Privy <br /> Sewage Disposal Field /00 Cesspool/Seepage Pit Other r <br /> Property Line Private Domestic Well Public Domestic Well F(. <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I` <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 //QI/('. <br /> ❑ DOMESTIC/PUBLIC ❑i�.�DRIVEN Gauge of Casing <br /> ❑ IRRIGATION XGRAVEL PACK Depth of Grout Seal D <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout . r Zt <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ Mate 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this perml t <br /> is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-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 will call for a Grout� S.JSInIpect on prior to grouting and a final Inspection. <br /> i •' rl <br /> Signed X -- 4 — Title: Date: <br /> (Drav4eplot Plan on Reverse Side) <br /> ^ FOR DEPARTMENT USE ONLY <br /> PHASE I: w+ n oZ / <br /> Application Accepted By Date <br /> Additional Comments: <br /> Ph se,)7 rout Inspection �( Phase 111 Final Inspection <br /> Inspection By ` _.Date _ Inspection By�J — Date <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑•January 1 A Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE f REMIT <br /> BASE EXPLANATION ��' DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE .� <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7d D <br /> Received by Oate Recelpt i, Petmn NO. I ante D t¢ I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: . ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bec 2009 STOCKTON.CA 95201 <br />