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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 CC tt Ordinance No. 1 2 the rules and regulations of the San J quin Local Hqafto District. <br /> Exact Site Address;� .� G /�/yr l� S G City/Town <br /> Owner's Name / f! t' �D'S '� / Z-.C� - Phone <br /> AddressCityn <br /> , �, <br /> Contractor's Na lec`ense Business Phone <br /> ��-� <br /> Contractor's Address- ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ,dam" No �N <br /> TYPE OF WORK (CHECK): NEW WELL 2�'76EEPEN ❑ RECONDITION❑ DESTRUCTION❑ " "^ -7'G <br /> WELL CHLORINATION ❑ WELL ABANDONMENT,❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 571:�. Sewer Lines S7 Q '- Pit Privy <br /> Sewage DisposalFigld Cesspool/Seepage Pit Other <br /> Property LinerPrivate Domestic Well, 'CS I Public Domestic Well <br /> INTENDED.USE TYPE OF WELL , <br /> ❑,.�,�INDU—STRIAL- 11CABLE TOOL Dia. of Well Excavation <br /> 2"DOMESTiC/PRIVATE r ❑ DRILLED" Dia. of Well Casing f <br /> 11DOMESTIC/PUBLIC 13, DRIVE'Nit I !� Gauge of Casing 1 f <br /> 11 IRRIGATION -,,❑I GRAVELrPACK r,, Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION NARY ' Type of Grout <br /> 1:1 DISPOSAL 0 OT�1ER p+ + <br /> a. _h s, Other l Grout <br /> —' IQ /irll. Urry� I <br /> ❑ GEOPHYSICAL to ;* %' ur a Seat Installed By:(- il <br /> PUMP INSTALLATION: Contractor it <br /> of Pup 'k`^_ } H. <br /> mP. ' <br /> PUMP REPLACEMENT: .F,�-� .­--p State Work, one __. <br /> 4 F � <br /> PUMP REPAIR: 11State V70'W"Done - S { �at <br /> DESTRUCTION OF.•WELL: h r , Well:Diameter t l .x Approximate'Depth <br /> 7.1 <br /> Describe Ma)eriai and Procedure <br /> I hereby certify that I have prepared this application and that the work will be,d6he in accordance with San Joaquin County <br /> 1 `ordinances, state laws, and rules and regulations of;the San Joaquin Local Health District. ; t <br /> Homeowner or licensed agent's signature C41ifies floe following:"I certify that in'the perforraanceof the work for which this permit <br /> fis issued, I shall not employ any person in such manner as to become subject to,workman's cbmpensalion laws of California." <br /> `"=Contractor's-hiring or sub contra .. signature certifies the following:"I certify;hat in the performance of the work forwhich this <br /> { permit is issued, I shall em Joy ) rson .subject to workman's compensation haws of California." <br /> r 1 I call for a Gr 1 sp ti p r to g ou'.g and a final inspection. '- 1 - <br /> If I <br /> Cniq <br /> Signed X. Title: , + Date: ! <br /> raw Plot Plan on Reverse Side) 4tj # <br /> � t � <br /> - FOR DEPARTMENT USE ONLY <br /> ASE I <br /> Application Accepted,By +`.,� Date ; <br /> s 4 �. <br /> E Additional Commends: <br /> se II"Grout Inspection Phase Final Inspection 6-1 + <br /> Inspection By !.. Date Inspection By atq, b! <br /> ♦, <br /> Fee ISDue: 11ANNUALLY ❑ PER UNIT m�D:PEWSIvV-E- -9—EACi�"'"""0'�yanCtai��1 S Received By January 31 ❑ July 1 &Received By July 31 Y <br /> , <br /> j BILLINCt3 REMITTANCE. $. AMOUNT DUE CHECKED <br /> $A E Q� EXPLANATION f <br /> DATE DATE .REMITTED AMOUNT <br /> FEE <br /> LESS. R .��RAa �,�- •---� I. _ { <br /> i PRORATION I <br /> PLUS r i } <br /> PENALTY <br /> I OTHER <br /> OTHER i <br /> I <br /> C� l <br /> —.,—Received-by---,. Dat .r...,.....ReceiplNo: ..` ..rPermit.No­­ ­,IssuanceDate", Mailed_ —,_Delive_red„",,,,•, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES A}~1(1131 E.HAZELTON AVE.,FW.Boa 2009 STOCKTON,CA 95201 <br />