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Applications Will Be Processed When Submitted ProperlyCompleted. Be Sure,Iosign Inerappncalwn. <br /> APPLICATION <br /> FOR OFFICE USE: 1 <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL x <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) I <br /> strict permit to construct and/or install the work herein"described.This application is <br /> Application is hereby made to the San Joaquin Local Health Di <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 f/-7Yl -46L✓PI -5- ' D City/Town P/ <br /> STEVE S ��!1.1 Phone 3110,17- IZZ <br /> Owner's Name <br /> Address Al!� City <br /> — <br /> Contractor's L_ License# Business Phone, <br /> Contractor's Name <br /> Contractor's Address 7poe x 4 W75 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK(CHECK): NEW WELL DEEPEN ❑ RECONDITIO DESTRUCTIO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATioNAL PUMP REPAIR❑ <br /> REPLACEMENT O <br /> DISTANCE TO NEAREST: I Septic Tank' Sewer Line � Pit Privy — =a <br /> �� . Cess ool/Seepage Pit Other t <br /> Sewage Disposal Field P <br /> Prpperty Line __Private Domestic Well - ` Public Domestic Well <br /> �. ter—•• <br /> INTENDED USE - '� <br /> ' .. .. "'.".TYPE OF WELL r <br /> ❑ INDUSTRIALCABLE TOOL Dia. of Well Excavation_ l��T, <br /> t <br /> DOMESTIC/PRIVATE ° DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 4 ❑ DRIVEN Gauge of Casing Q <br /> ❑ IRRIGATION _ ❑ GRAVEL PACK ; Depth of Grout Seal _ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> DISPOSAL OTHER Other information <br /> ❑ GEOPHYSICAL I Surface Seal Installed By: <br /> s Contractor <br /> PUMPINS <br /> i Type of Pump � i�G?'6. a'/ —� H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 1:1State Work Done °� F <br />` DESTRUCTION OF WELL: : ; iWell Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I.have.preparedthisapplication-and-that"the work will-beldone 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 permit <br /> is issued, I shall hot 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 perfo"rmance of the work forwhich this r0 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." T <br /> I wil' all for a Gr'ut Inspectio nor.to grouting and a final inspection. v�Ca <br /> Signed X � ._ Title: [[// — Date /l <br /> •(praw-;Plot Plan.on Reverse Side)-- "`.'a <br /> F ! FOR DEPARTMENT USE ONLY <br /> PHASEI �.---- .. Date <br /> Application Accepted By 1 <br /> Additional Comments' - it p )Z JJ�� <br /> Phase II Grout Inspection P se III Final Inspect ' / •! <br /> Inspection By Date Inspection By Da <br /> r. <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 &Received <br /> EMIITuly 31 <br /> BASE <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> .k_ <br /> 0 <br /> FEE. <br /> PRORATION <br /> I PLUS <br /> r PENALTY, <br /> 1` OTHER <br /> ' OTHER <br /> F <br /> Issua ce Date Mailed <br /> ReceiverJby ate - Receipt No. Hermit No, De4ivere <br /> 1. _ d _ 1601 E <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES E.HAZELTON AYE.,P.O.-Box 2009 STOCKTON,CA 95201 <br />