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J Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR,PFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) / <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No 1862 and the rules and regulations of the Sa_rLJoaquin Local Health District. <br /> Exact Site Addressp ��TQ ..�... �.• City/Town <br /> A�t/ .5 <br /> Owner's Name �.+ AKI_�i ,f s] 6 L � .��„�� Phone r _ <br /> Address g2kQ IS 4' ► &,*A Z7A City 4�, AL- ov— <br /> Contractor's Name ) $Q/�.C,/ t1se •L Business Phone__ � <br /> Contractor's Address .6 8� � r4 LG�i�1 -iergency Phone cS /e'r!'*�7 <br /> is Certificate of Workman's CompensationIns rance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ' G/ f Sewer Lines _ Pit Privy�Q # _ f�� <br /> Sewage Disposal Field �� '�" Cessp--oo/ll/S�eepage Pit �1� Qthe /y <br /> Property Linew� Private Domestic Well � Public Domestic Well )V <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing CL/�5S l dycC <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION WROTARY Type of Grout S--AIT' <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 44VT—&4 C Tri � N <br /> PUMP INSTALLATION: Contractor 1r+I-A fir+/ mc'i ���E. --*W <br /> ,- -' <br /> Type of Pump u 1 H.P. r[C? <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 /> 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, 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 em p persons subject to work an's compensation laws of California." <br /> I will I for a Gr fns a Ion or to uting and final inspec ' <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FORD PARTME USE ONLY <br /> PHASE I <br /> Application Accepted By Date 7 <br /> Additional Comments: oe <br /> Phase II Grout Inspection �p PhaseIII Final c_ do <br /> Inspection By \.0�� Date_ rr. , LInspection By ate <br /> rcr \rat <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />