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Applications Will Be Processed When Submitted Properly Com le eii;!. e n The Application. <br /> FOR OFFICE USE: APPLI II'� � ; <br /> k Lit <br /> (For Non-Transferable, a11# ,'SLspen able} PUMP&WELL <br /> ENVIRONMENTA ALT REPII %82 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permittQCf�ptrl�Qi II staly �ayr�rkhereindescribed.Thisapplicationis <br /> ;3113 36J 9 1_iJ�f1L <br /> made in compliance with San Joa uin Count Ordinance Ngg 1862 and the rules iq Joa ui Local Health District. <br /> Exact site Address yJAI 5LL.S �;c'y � L �� <br /> Owner's Nam PhoneQ— <br /> Address - 09.7 a AJ City <br /> Contractor's Name License Business Phone `-«aZy <br /> Contractor's Addres Emergency Phone Qhs h &_ 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No - ><1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN X RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ /] <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit�Privy/ o XAe— <br /> Sewage Disposal Field 0 Cesspool/Seepage Pit/V/C6 /7 e I Other <br /> ' <br /> Property Line L Private Domestic Well Public Domestic WelIA O AJ&- <br /> INTENDED USE TYPE OF WELL / it <br /> ❑ INDUSTRIAL �E - BLE TOOL Dia. of Well Excavation / <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> %IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal n,O <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout )n <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: n 'ems <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 O <br /> Describe Material and Procedure <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. C <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, .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 forwhich this r..� <br /> permit is issued, I shall employ persons subject to workman's compensation laws of-California." (/) <br /> I til call for a-'Grout Ins ction prior to grouting and a final inspection. <br /> Signed X Title: _ ,f B? "t2� Date: : — a— Z.*,- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE1 r <br /> Application Accepted By r—e'a-' U ` Date <br /> Additional Comments: ' <br /> Phase II Grhpt inspection ase III inspection <br /> Inspection By Date Inspection By e ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> J r_ AMOUNT <br /> FEE (t) ` nD c.y IcLr <br /> LESS j <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> y <br /> ceive y Date RecF o- Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11601 E.HAZ£LTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />