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_ Applications� Be Processed When Submitted rope <br /> APPLICATION ' <br /> FOR OFFICE USE: t <br /> ' (For Non-Transferable, Revocable, Suspendable) <br /> PUMPf7ELL �. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework,herein described.This application Is <br /> made in compliance wa oaquin Count din nce No, 1862 and the rules and regulations of the Sa�n+�oadum,LQcapeai istri �� <br /> , (� U City/Town T7T 1e� y ! <br /> Exact.Site Address / ` f b N <br /> Y ICS Phone�` �/ O TJ <br /> Owner's Name City <br /> Address Q� 7thIII <br /> L tP License# �. 3 Business Phone <br /> 's Name f3s <br /> Contractort✓jYSo <br /> �- lFc T Emergency Phone <br /> Contractor's Address __ No i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION Q' WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION 11 PUMP REPAIR❑ <br /> REPLACEMENT❑ G " Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank, Sewer Lines y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line _ Private Domestic Well Public Domestic Well <br /> INTENDED USE �� TYPE OF WELL <br /> 13 INDUSTRIAL r''❑ CABLE TOOL Dia. of Well Excavation ter„ <br /> ❑ DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC © DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> 11GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> N.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done s5� 1 N <br /> 50 <br /> PUMP REPAIR: 15 State Work Don � , <br /> �rt �or� Approximate ept <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared t�Isulapolnstof the San Joaqu n Locaiwill <br /> Heaitdone <br /> h DistrictCcordance with San Joaquin County <br /> ordinances, state laws, and 9 <br /> or licensed agent's signature certifies the following:"I certify that in the performanceof the work for which this permit <br /> Home ownermanner as to become not employ any person in such subject to workman's compensation laws of California." <br /> is issued, I or l <br /> I "I certify that in the performance of the work forwhich this <br /> Contractor's hiring or sub-contracting signature certifies the following: <br /> permit is i d, I shall emplr ersons subject to workman's coit' <br /> sation laws of California." <br /> wi or ut Ins ction p or to grouting and a final insn. <br /> Title. Date: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> i r —FO DEPART ENT USE ONLY <br /> .../, <br /> PHASE 1Date <br /> � <br /> Application Accepted By <br /> Additional Comments: Phase Ili Final Inspection <br /> K Phase I Grout Inspection <br /> Date— inspection By <br /> Date <br /> Inspection By - <br /> ' <br /> January 31 July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑-EACH '❑ January 1 &Received By ❑ <br /> REMIT <br /> I BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> BASE EXPLANATION DATE DATE OREMITTEO AMOUNT . <br /> F FEE <br /> LESS t <br /> PRORATION _ <br /> r PLUS <br /> PENALTY f '� <br /> t OTHER <br /> i OTHER <br /> ailed <br /> Received 6 x. Receipt No Permit No. Issuance Date -60x 2 Delivered <br /> y Dale <br /> 1601 E.HA2ELTON AVE.,P.O.Box 2009' -STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES `�–/ <br />