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A$f. c616,sWII;ie140 Iss 4 W n ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> JUN .. or Non-Transferable, Revocable,Suspendable) <br /> �}��� 11 19azPUMP&WELL <br /> L-0'PO <br /> bio MN ENTAL HEALTH PERMIT <br /> AN JDP%QUj�� �L WATERUALITY 2—[?- —(/e/-®2- <br /> (COMPLETE IN TRIPLICATE gp 1SN ICT Q .� � <br /> Application is hereby made toth afl' oUtii ocal ealthDistrictforapermittoconstruct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules.and regulations of the San Joaquin Local Health District, <br /> Exact Site Address City/Yawn G° Y <br /> + "\1 <br /> Owner's Name `J Phone e2 2 <br /> Address �- �� _.. ..__C�+ t City <br /> Contractor's Name 6License#2- kc,K Business Phone- <br /> Contractor's Address KV, '7466 • MAaMe� Emergency Phone `" "' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No r ' <br /> TYPE OF WORK (CHECK): 'NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ {� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing a `F <br /> IRRIGATION suC } ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout { f1 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: d <br /> PUMP INSTALLATION: Contractor d C_IAC -a.48d T <br /> Type of Pump ` m <br /> H.P. go 1 i <br /> PUMP REPLACEMENT: a❑�t State Work Done �R <br /> PUMP REPAIR: ya State Work Done 6 F <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dept <br /> r Describe Material and Procedure J m l <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-subjec[to:workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that n the performance of the work torwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi call for a Grout In ection prior to grouting and a final inspect G _ m <br /> Signed X � - Title: 4 �'+�' Date: <br /> (Draw Piot Plan ori Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted B w'�`^' Date <br /> Additional Comments# <br /> 5 - dcs•�+- s <br /> Phase It Grout Inspection c y P e II Final Inspection ,� <br /> a <br /> Inspection By—{ Date Inspection By Date �- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑-January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> - .4 REMIT <br /> BILLING REMITTANCE $ I <br /> BASE EXPLANATION DATE - DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> . OTHER <br /> Received by Date Q Receipt No, Permit No: 1ss nce a e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1150 E.HAZELTON AVE.,P.O.Sox 2DD9 STOCKTON.CA 95201 <br />