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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL -* <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE" IN TRIPLICATE) WATER QUALITY � <br /> Application is hereby made to the 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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 259-11 Miller Road City/Town <br /> Owner's Name Rill Burrows Phone 839-7973_ ' <br /> Address -75933- City F ae a lon <br /> t <br /> Contractor's Name Mart-1-n Film-p & Supply Tnc License 0.360-8153 Business Phone <br /> Contractor's Address _ 75ReedRoad Emergency Phone G' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELLJO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION® PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 751+ Pit Privy None <br /> Sewage Disposal Field ]-001 Cesspool/Seepage Pit Other <br /> Property Line 3301 Private Domestic Well 100 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 11tt <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 518" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 33 _ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 501 # <br /> ❑ CATHODIC PROTECTION IN ROTARY Type of Grout Bentonitp <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:Martin Pump & SuPP1 Y lnc <br /> PUMP INSTALLATION: Contractor Martin PqmR Supply Inc <br /> Type of Pump Siihm H.P, 1 <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 /> Conlractor'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 wl for a Grout Inspection p for to grouting and a final Inspecti <br /> Signed X� Till.- Date: <br /> (Draw P)6t Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI ✓ Q <br /> Application Accepted By _- AreaaG Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P s 11 Final Inspection <br /> Inspection By Date Inspection 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMDUNT DUE CHECKED <br /> AMOUNT <br /> FEE $ ' C'o.a qL3 g�` Ca <br /> LESS <br /> PRORATION <br /> PLUS99 ✓ <br /> PENALTY { C-5 /�"'�"1Zlt h\w <br /> I Pr Vt+�f <br /> OTHERJ -t-ro»-,tt4,L Lrt <br /> OTHER of a&ev l c d{) +"� LrtI�G✓r--r f/' +r. .�jrf rZ b. <br /> 7714e- f.atslef, <br /> Received by Date - Receipt No. PermQ No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BoK 2009 STOCKTON,CA 95201 ' <br />