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Ap fidtii�osWfil66Wec6se�,W ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> OCT 'E 5 19Mr Non- ransterable, Revocable, Suspendable) PUMP&WELL <br /> J ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLiCAT � � `)�'' EJ •'! 1..;7CAL WATER QUALITY <br /> TT���� -,i <br /> Application is hereby made to thH,9A J�aq�ii'4-L'OVAIF�I@e A 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. City/Town /t2- .2 c� <br /> Owner's Name Phone <br /> Address !' -,-.e�J a,v�L- 1� City <br /> Contractor's Name 149 License 47 ®PAG Business Phone <br /> Contractor's Address 40, ZoX 2 , Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Z---" No C>8 <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER I9 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 Public Domestic Well <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 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION' ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ��`�e—&&eu+/� <br /> Type of Pump I H,P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: M 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 /> 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 employ persons subject to workman's compensation laws of California." <br /> I will/call for a Gr ection prior to grouting and a final insp n. <br /> Signed X X�/ & Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> rl OR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By U(�G� 1`3 Date <br /> Additional Comments: <br /> Phase II Grout Inspection as .III Final Inspection <br /> Inspection By 1A 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> ,y �[ AMOUNT <br /> FEE W 1 S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> /y? - /0 15 a 527 <br /> Received by Dalte I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O.Box 2009 STDCKTON, A fl <br />