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-" Applillaki6hs W'It ,P cisg`���y�}'�("T'en`Samitted Properly Completed. Be Sure To Sign The Appllcatlon: 'T <br /> 1'I �+ �7 F I V V ! _ v a 4 <br /> FOR Off IGi.usE: APPLICATION � , <br /> (For Non-Transferable, Revocable, Suspendable) I <br /> SAN JCAQUIN LOCAL PUMP&WELL � <br /> HEALTH DISNVJWNMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with gan Joaq Co Int rdinanceNpo. 1862 and the rules and regulations of the San Joaquin Local Health District.: <br />{ Exact Site Address 670 . � / - City/Town �C <br /> Owner's Name — PhoneT <br /> Address f [" Cityf , a <br /> Contractor's Name c' f ,1 S License# v79449J9Z Business Phone <br /> Contractor's Address Emergency Phone <br /> . <br /> Is Certificate of Workman's Compensation ii nsurance on File With SJLHD? Yes No r <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> N WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR. { <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well d Public Domestic Well <br /> INTENDED USE # TYPE OF WELL I <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 Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL (t Su face Seal Installed By: 0 ,' <br /> PUMP INSTALLATION: Contractor 25fn�T ,-r` C_-_ 4 <br /> Type of Pumpl 1_ H.P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Z State Work Done .1. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . I <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-contractingsignature 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 willfor G77-42 <br /> spection.prior to grouting and a final inspection <br /> ca <br /> Signed X Title: Date: <br /> .. (Draw.Plot Plan on Revers_e ide). <br /> - FO EPAR"MENT U`"-TQNLY� <br /> PHASEI <br /> Application Accepted By Date <br /> s Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re9 211y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE /REMITTED AMOUNTDUE CHECKED <br /> ' AMOUNT <br /> FEE... <br /> LESS A � r I <br /> PRORATION <br /> PLUS r U <br /> PENALTY �11 dr <br /> _ b <br /> OTHER <br /> OTHER _ JJ <br /> I '? <br /> I+ . 3 � � ` � <br /> Received by Date ;' Receipt No. -Permit No. Issuance Date Mailed Delivered e <br /> APPLICANT—RETURN ALL COPIES TO: r'ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON,CA 95201 4 <br />