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Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. <br /> Fc'?i OFcxCE USE: APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WEi_I. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application 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 Joa_yin Count Ordinance No. 1862 and the rules and regulations of the Sa quin Local Health District. <br /> Exact Site Address -7 / O o City/Town e6 Art CA--i <br /> Owner's Name D/YLt // hz-- �R Phone 57 CP <br /> Address 4 —CA-'— I Pa /1r City 1 eo I" . clsa:, <br /> Contractor's Name u9 License#�/�!9 Sr.S/ Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL R!"�_ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0-'PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 16 O-4^ Se�/rer Lines �� Pit Privy <br /> Sewage Disposal Disposal Field U -74-- Cesspool/Seepage Pit /�- Other <br /> Property Line Private Domestic Well � Public Domestic Well ----- <br /> INTENDED <br /> INTENDED USE TYPE OF WELL / 1/ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout 5e�,1 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout ���5 "ta1✓I eu&r -, cl. <br /> ❑ DISPOSAL ❑ OTHER Other Information -"' e <br /> ❑ GEOPHYSICAL Surface Seal Installed By:`�. e S., f MC_. <br /> PUMP INSTALLATION: Contractor—� i ► / <br /> Type of Pumper — ___.. H.P. (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 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 otthe 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 forwhich this <br /> permit is issued, I shall emlo ons subject to workman's compensation laws of California." <br /> E I call for a Gro p ti rio t grouting and a final inspection. <br /> Si Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DE ARTM764, <br /> USE ONLY <br /> PHASE <br /> Application Accepted By ,' '^+ 6 Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Nr 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 AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> J13N 2/0 <br /> Received by IDate I Receipt No. Permit No. Is uance Date Mailed Deli r d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO TON,CA 95201 <br />