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y Applications Will Be Processed When Submitted Properly Completed 5u T!i� h lication. <br /> c'"f�R FOR OFF CE�'ASE: APPLICATION �-� <br /> (Far Non-Transferable, Revoca ug <br /> may- '; PUMP&WELL <br /> ENVIRONMENTAL HEAL ERMIT <br /> QUALITY <br /> (COMPLETE IN TRIPLICATE) WATER ' <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/orinst 14-hie'*rAr��idescribed.This application is w ;. <br /> made in compliance wi7th San Joaquin�C7oun Ordinance N . 1862 and the rules and regi ls-O�t'1j1l� In Local Health District. <br /> Exact Site Address v545 4 /+ WC3wn ! <br /> Owner's Name t- Phone -' 3 2l—A— <br /> Owner's e <br /> Address 3 ca es _77. o-w-e�t1 � City <br /> LXJ <br /> Contractor's Name �,�.P �- �1 License# ll � 37-3 Business Phone <br /> Contractor's Address Emergency Phone _s �C., <br /> Is Certificate of Workman's Compensation Insurance on File"With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR W <br /> REPLACEMENT❑ <br /> F <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other t <br /> Property Line` Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - Y <br /> ❑ DOMESTIC/PRIVATE ❑'DRILLED -Dia. of WeII Casing' , t - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of.Casing <br /> &fRRIGATION __T. _ .__ ❑-GRAVEL PACK_ Depth of Grout Sea) <br /> ❑'CATHODIC PROTECTION ❑ ROTARY r- Type of Grout 1f <br /> i ::. �� E <br /> ,_fl DISPOSAL * .❑ OTHER .g. =Other Information <br /> ❑ GEOPHYSICAL M1 Sur fce Seal Installed By: YJ <br /> PUMP INSTALLATION: Contractor^ , <br /> ,Type of Pump H.P. = <br /> PUMP REPLACEMENT: '❑ State Work Done <br /> PUMP REPAIR: 'State Work Done' <br /> DESTRUCTION OF WELL:_ ; Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 24 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County C <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 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 the performance of the work for which this I <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." <br /> I cal =oraout lnsion prior to ting and a final inspection. <br /> Signed X Title: 139w�/L Date: d <br /> 4 (Draw PI t an on Reverse Side) <br /> t <br /> FOR DEPARTMENT USE ONLY `y` <br /> PHASEI <br /> Application Accepted By � .._ Date <br /> Additional Comments: ' <br /> Phase II Grout Inspection Ph se III Fina! Inspection <br /> Inspection By Date inspection By A Date p <br /> Fee Is Due: ElANNUALLY ElPER UNIT ElPER SITE 1:1EACH El January 1 8 Received By January 31. . ❑ July 1 &Received By July 31 t <br /> REMIT J <br /> 5 ]!D <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE. REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OT HER <br /> OTHER !!! I <br /> v Received by Date Receipt No. Permit No.. Isshance date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES-TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2005 STOCKTON,-CA 95201 <br />