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Applications Will Be Processed WhenSubmitted ProperlyCompleted. BeSureToSign TheAppiicatlon. <br /> FOR OFFICE USE: APPLICATION 1 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> - PUMP&WELL <br /> ENVIRONMEN_TAL.HEALTH PERMIT <br /> . �-•�,taro <br /> (COMPLETE IN TRIPLICATE) Y WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the San Joaquin Local Health District. , <br /> Exact Site Address <br /> Owner's <br /> le�• City/Yawn df7 <br /> Owner's Name D Phone _334— S! 74 <br /> Address Al, tr.&ZM4 GitY_..__Ac4W40low <br /> f <br /> Contractor's Name 6,60 A License#33 70o '2--Gusiness Phone 7,2F—:3 37� <br /> Contractor's Address 7r 3 Z4 e �(:At–` Emergency Phone 7� W <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN P- RECONDITION tj DESTRUCTION❑ <br /> 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C> <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 14g7fa Sewer Lines /Al-er'? 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_TO. OL Dia. of Well Excavation _ <br /> 11 DOMESTIC/PRIVATE ❑ DRILLED �. Dia. of Well Casing _- <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �0 <br /> P IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 5� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ g �/�e5 (42"dIGP— <br /> ❑ DISPOSAL ❑ OTHER Other Information j <br /> ❑ GEOPHYSICAL Surface Seal Installed By: __FY1ST/ G� s <br /> PUMP INSTALLATION: Contractor 7szFua71__r-sI <br /> Type of Pump �do - H.P. /S~ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DA(STRUCTION 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. i <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit i <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 /> I <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I =callr a Grout Inspection prior to grouting and a final inspection.Signed X �D Title: &-It taezzil Date: _3—a 3� — •a <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> /01 77 a <br /> Application Accepted By Datevl I <br /> r <br /> j Additional Comments: �l <br /> e II Grout Inspection , J I11 Final Inspection <br /> _�ATInspection By Dater Inspection ByArftse <br /> Date <br /> i <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 DATE DATE REMITTEp AMOUNT DUE CHECKED <br /> AMOUNT Al <br /> 00 <br /> a c ! <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER I <br /> Received by Date Receipt No. .Permit No. I scan a ate Mailed OelWered <br /> I. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES- _ - 1601 E.HAZELTON AVE.,P.O.Boa 2009- STOCKTON,CA 95201 <br />