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cations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> * APPLICATION <br /> (f=or Non-T.r�f4a'ble, Revocable,Suspendabte) <br /> . __. ....PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT e <br /> (COMPLETE IN TRIPLICATE) f 715'x' S, rtr..ic �/ WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Dist Kit for a permit to construct and/or install the work herein described. This application is �f <br /> made in compliance with San Joaquin County Oldinance No. 1862 and the rules and regulations of the San Joaquin Local Health Dis ict. <br /> Exact Site Address L-0It(Se. ���.�/h�C'� AtiQ"at �s- <br /> m s' City/Town �Cl7 �a, <br /> Owner's Name 2Ce;,10,,A,1 .Grp%��¢'��� � Phone <br /> 1 Address ,36y y1 fF city o—,-- , r� <br /> Contractor's Named is G✓ SSuc <br /> License# Business Phone <br /> Contractor's ne <br /> Contractor's Address Cr �)C-kT tEmer encyPhone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NeT- <br /> TYPE OF WORK (CHECK): NEW WELL q DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION R PUMP REPAIR <br /> e REPLACEMENT❑ <br /> DISTANCE TO NEAREST:. Septic Tank Sewer Lines Pit Privy <br /> h Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line .30/ Private Domestic Well ^— Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL - ❑ CABLE TOOL Dia. of Well Excavation _ <br /> ❑ DOMESTIC/PRIVATE :0 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �� J <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout f e_11,7 <br /> ❑ DISPOSAL r, ❑ OTHER Other Information <br /> W,GEGPFFY81G L tj,�L/ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump4 �� H.P. <br /> r <br /> PUMP REPLACEMENT: State Work Done f <br /> PUMP REPAIR; State Work Done <br /> DESTRUCTION OF WELL: fi Well Diameter AeZoximate Depth � . <br /> Describe Material and Procedur <br /> ! 1utt zri <br /> I hereby cer fy ttlat I have prepared this a plication and that the work will one in accordance with San Joa In County <br /> i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ]j <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." fT1 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work€orwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will�call for a Gro t Inspec lo prior to grouting and a final inspection. <br /> D C_- <br /> Signed X4f-14, <br /> Title: "' ✓ Date: <br /> 4 �y (Draw Plot Plan on ReverseSide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By � ., ~?"-, _ Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection , <br /> Inspection By Date Inspection By LL5ate Q <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 ❑ EACH ❑ January 1 &Received By January 31 ElJuly&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ <br /> DATE DATE REM[TTED AMOUNT DUE CHECKED <br /> 1 AMOUNT <br /> L <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 95201 <br />