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E • Applications Will Be Processed When Submitted Properly Completed Be SureTosign IneRppneitsuvn• , <br /> E�'Qffk�E USE: APPLICATION I (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is IN <br /> RI ICAadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/or install the work.herein described.This application isherI <br /> Ordinance No. 1862 and the rules and regulations / the San Joaquin Local Health District. <br /> made in compliance.with San Joaquin County y/ N f <br />` 3 �• � �G'o EUT��� City / aP 'L�-L LI= <br /> ' Exact Site Address LD V�<e �tJ N �— C4 <br /> ©C L Phone i <br /> Owner's lys'ime p L)FO f 110 C' <br /> Address _(!I -67,b x- City <br /> - License# Business Phone <br /> Contractor's Name -L . V L .� <br /> L S <br /> F Contractor's Address Z82 E Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑. WELL ABANDONMENT J9 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 •I --$' T- <br /> INTENDED USE TYPE OF WELL r I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE MDRILLED Dia. of Well Casing r- <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout iiL26-Pr r_�^-� <br /> ❑ DISPOSAL 1❑ OTHER Other Information [ <br /> R �_ C E-o 7-c �q N i c fN.L- S rface Seal Installed By: J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f11State Work Done <br /> PUMP REPLACEMENT: <br /> t PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter AppU <br /> Describe Material and Procedure <br /> t <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 subject to workman's,compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in th2.performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i I will call for a Grout Inspection prior t;grouting and a final inspection. <br /> Date: Z Ctt'8 <br /> Signed X . � KG I f-'f—t S Title: <br /> (Draw Plot Plan on Reverse Side) <br /> it FOR DEPARTMENT USE ONLY <br /> PHASE 1 j' <br /> Date <br /> Application Accepted By <br /> Ir <br /> Additional Comments: <br /> Phase II Grout Inspection 42 se III �jlpectionA <br /> r <br /> Inspection By Date Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received BY EMIT my 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT RUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 3 1 3 <br /> FEE f <br /> LESS <br /> PRORATION <br /> t PLUS <br /> I PENALTY <br /> OTHER <br /> OTHER <br /> �# <br /> Received by <br /> Date 'k ,. Receipt No. Permit No, IssUance Date Mailed Delivered - <br /> 164TE.HAZELTON AVE.,P.O.Box 2045. STOCKTON,CA 95 <br /> 201 <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />