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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 for a 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 rulesJand.regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1775 ` E HlghiLVV 4 A City/Town strtckton " <br /> Owner's Name Phone 941 -8515 <br /> Address -1.7-750-'P. Hi 42�hw@-y LL "­". = City t <br /> Contractor's Name Lark Weil fi. "Frt It i s ment- License#i' Business'Phone.' 462-3597 <br /> Contractor's Address 2,02. 4 F. rha,rtL-r 112 V .t'." _ Emergency Phone" N <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No C_ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ _` RECONDITION❑ -DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL`ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank -F100Sewer Lines Pit Privy <br /> Sewage Disposal Field - Cesspool/Seepage Pit - Other <br /> " Property Line +100 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 /> kXDOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ .GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION IROTARY Type of Grout 9 }cork mi sr Sand & Carnpn <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface-Seal Installed By:,. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ 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 /> 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-contracting signature certifies the following:"I certity that in the performance of the work for which this <br /> permit is issued, I shall mpl y peFlip <br /> ject t workman's compensation laws of-California." <br /> I ill c I or.a rou Inct or u i and a final inspection. - } <br /> Signed Xf" Title: - Date: 1.7 MA.j2f-.h 1983 <br /> (Dra Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE - <br /> Application Accepted By ' Date _ <br /> Additional Comments: <br /> Phase II Grout I ection`/ Phase ISI Final Inspection <br /> Inspection By Dated Yl�� _ Inspection By ���y� Date <br /> - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 1 ❑ 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 REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No:- Permit No r I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.-HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />