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s11V1 Be�toctQr <br /> WhenSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE \„ t APPLICATION <br /> Non-Transferable, Revocable, Suspendable) ` <br /> JAN o I ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> 2'�l 4P 7 5 Lc u[o._1 20 <br /> (COMPLETE IN TRI khan <br /> MA U1N LO�A�.1 WATER QUALITY 2S r7 —eta <br /> Application is herebyiratF al > &TalHealth Districtforapermit toconstruct and/or install the work herein described.This application is <br /> made in compliance wJoaquin County Ordinance No. 1862 and the rules and regulat' ns of the San Joaquin Local Health District. <br /> Exact Site Address U S ( '/ 11,6x6?! City/Town /lam 1 G� 09, <br /> Owner's Name Plee H0F ^j1V' <br /> Phone a 3 oC <br /> Address7 7& ESC" Gity R <br /> Contractor's Name �� License# P,ZSBusiness Phone <br /> Contractor's Address _ �� hL/Z /3.,?A /pG✓l� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on FG With SJLHD? Yes ' <br /> �� No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN El RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP iNSTALLATION)J 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 /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor /Y',^//T` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: X ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth rt <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. ww <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 oru In�tion prior tng and a final inspection. <br /> Signed X Title: _ �2 9--- ` <br /> Date: <br /> (Draw Plot Plan on Reverse Side)` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �/- ��, -CJ pj, <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> Pha II Grout Inspectionhas I Final Inspection _ <br /> Inspection By Date Inspection By Gl^–pate —�.5 <br /> s <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 [J July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REWT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S <br /> Received by Date 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 STOCKTON,CA 95201 <br />