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Applications Will Be Processed WhenSubmitted Properlyuompletea.tsesure Iosign inemippn-auvn. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Appl ication is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San oaquin County Ordinance No. 1862 and the rules and regulations of the San Joaq in Local Health District. <br /> 7' <br /> Exact Site Address 112 N—Xc ro�i 6 � City/Town /lode <br /> Owner's Name1'elrsl+e ✓r V Phone -� b X77 <br /> Address - City— 0 £S7_0 <br /> Contractor's Name CLARK wI -LF ulA ��C License# Business Phone_. '�"`lia '2 2CT77 <br /> Contractor's Address 24 24 -=, U+011VI OA Emergency Phone Vd A169- <br /> Is Certificate of Workman's Compensation InsuJ3nce on file With SJLi Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ j <br /> REPLACEMENT❑ /Vb? +�^` /�'T/NG A7- 7lyl.:'/� WXe <br /> DISTANCE TO NEAREST: Septic Tank `f Sewer Lines G V Pit Priv <br /> Sewage Disposal Field T 6d ! Cesspool/Seepage Pit A/6 A)dI` Other <br /> 15 i <br /> Property Line Private Domestic Welli 300 ' Public Domestic Well <br /> INTENDED USE TYPE OF WELL /ep <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation— <br /> DOMESTIC/PRIVATE <br /> xcavation DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing a <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 S'TFEk <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �© <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Slow,--44 C4. xm <br /> Type of Pump S H.P. Z <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 County <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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Gra Inspectio prior to grouting and a final inspection. <br /> Signed X ,��� z3 _ /'Title: Date: ! <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DE ARTMENT USE ONLY <br /> PHAS <br /> Application <br /> 1 <br /> �� q <br /> Application Accepted By �"^ Date 1 71 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Fina eclion <br /> Inspection By �' ' �' Date 9-- Z, -0y ion By Date � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE f/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received.by Date Receipt No. Permit No. f lsOs nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKY N,CA 55201 <br /> C <br />