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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> MOFFI APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE)'-/3 QUALITY S <br /> ©s <br /> Application is hereby made to the San Joaquin Local Health Districtfora.permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 andthe rules andiregulations of the San Joaquin Local Health District. <br /> Exact Site Address 1Mile east—D-f-_1 on MA-rJDoSqJatk Tone <br /> City/Town <br /> Owner's Name -firiaPhone <br /> Address Sam PGty <br /> Contractor's Name C1laxk--Wel 1 E.c}ta:-1_1.Mt✓3 t License#3'Z1 �,o %n Business Phone' 469_ <br /> 4 597 <br /> Contractor's Addres Emergency Phone NA- <br />` is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL <br /> q{ DEEPEN IT RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONME T OTHER 11 PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ ort o� <br /> DISTANCE TO NEAREST: Septic Tank oSewer Lines Pit Privy <br /> 'Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line +1 n 0 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> gCDOMESTIC/PRIVATE ❑ DRILLED 1 Dia. of Well Casing ,t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> . 125 Steel <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION XIR ROTARY Type of Grout - Ben ri1 e <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin�rlw <br /> _. ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that 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 workman's compensation laws of California." <br /> Contractor's hiring or sub-contrac' si ature certifies the following:"1 certify that in the performance of the work forwhich this <br /> permit is issued, I sh employ rs s bject to workman's compensation laws of California." <br /> I w' I ora r ui s con p.or t u and a final Inspection. <br /> Signed X Title: <br /> Date: Oct 14- 1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i . �. <br /> Application Accepted By Date ' <br /> Additional Comments: <br /> Phase II Grout Inspectlon <br /> f /Phas Fi 1�[lspection <br /> Inspection By Date InspectionIBy a /.7--;Lb-83 <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January,1 8&RecEived By January 31 ❑ July, 1 &Received By Juty 31 <br /> YBILLING REMITTANCE $ REMIT <br /> 'BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT. <br /> FEE- qty 0 <br /> LESS �f <br /> PRORATION <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 2. <br /> Received by - Date - Receipt No Permit No, Isssance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />�y i <br />