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fr ApplicationsWill Be Processed When Submitted Properly Completed. I r e'ttn <br /> P YIo159g�m'�he'Aplio - <br /> FooFFlc usE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) NOV 24 IJOU ~ <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> - -- -- SAN JOAQUIN LOCAL' <br /> • (COMPLETE IN TRIPLIGATE): � �'"- - - - �QUALI Y � <br /> Joaqui`G'fw Fes. r e; , n � ��ALT i DISTRICT �'Sg-C �a--0 2.: <br /> Application is hereby made to t e San Joaquin'LocaI Health District fora permitto construct and/or inst I ewor herein described.This application is <br /> made in compliance wjth San Joaquin County rdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �i p. _ y <br /> L OD v f/14k, City/Town Lndr 7 <br /> " - 1 .SLI�YaMGH�O <br /> Owner's Name Rd.�C <br /> ` Address d 1nPhone), I/1 rt <br /> Contractor's NameVicillers Drilling CCity <br /> arp. L <br /> ILicense#�3 Business Phone 31 -y! <br /> Contractor's Address D <br /> o - Emergency Phone <br /> Is Certificate of Wrkman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 1-1DEEPEN 11RECONDITION 11 DESTRUCTION❑ <br /> REPLACEMENTS 1 " <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ClREPAIR OTHER ❑ PUMP ❑ .Q <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> t Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> i: INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL = 11 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ t Tt <br /> DRILLED Dia. of Well Casing.- <br /> ❑ DOMESTIC/PUBLIC 1:1 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 /> ❑ GEOPHYSICAL f� al Installed By; <br /> PUMP INSTALLATION: x. Contractor Pptyiance Drillers Drl�'rlgt�bi <br /> 'Type of Pump--- _State tH.P.PUMP REPLACEMENT: SD <br /> ,��W <br /> S O <br /> PUMP REPAIR: - State Work Done <br /> T, DESTRU( UN OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> r 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-Sari Joaquin Local Health.-District. _ :,� h <br /> I� ;t <br /> Home owner or licensed agent's signature certifies the following:"I certifyYthat in the performance of the work forwhich this permit <br /> is issued,-I-shall not employ any person in such manner as to become-subject'to-workmarils_compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons-subject to workman's compensation laws of California." <br /> I will call for Gr spection prior to grouting and a final inspection. <br /> r <br /> Signed X �f -,r— <br /> Title: S/� l Date: _� <br /> {Draw-Plot`Plan on Reverse Side)"�"""" """- <br /> 7 !4 <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: <br /> Date <br /> Phase II Grout Inspect on <br /> Phase III Final Inspection <br /> Inspection By Dat r Inspection By Date <br /> y I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PEA•SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jury 1 &Received By Juiy 31 <br /> BASE EXPLANATION �,BILLING REMITTANCE REMIT <br /> $ AMOUNT DUE CHECKED <br /> !DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY' II <br /> OTHER <br /> OTHER <br /> Received by �. pate <br /> ,,. Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ..� - 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 <br />