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Applications Will Be Processed When Submitted ProperlyCompleted tie <br /> er�r "• <br /> FOR OFF4GE USE: APPLICATION ;41, <br /> (For Non-Transferable, Revoca sPUMP&WELL <br /> ENVIRONMENTAL HEAL ERMIITf �g79 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or instal�t�ie�y�rl .described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and reg� +t( rls�5f'tllllTLocal Health District <br /> Exac Site Address n ess — riE' hou. — See <br /> b� 0 , W aa� re way h �r a <br /> tt Phone b <br /> Hers Name _ Glen'" 1ba City S ockton <br /> Address 3627 14 Mile D iv 727-5548 <br /> Contractor's Name Goehriri Pum License#309031 Business Phone <br /> Emergency Phone <br /> Contractor's Address _17754 N. H S - No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX <br /> TYPE OF WORK (CHECK): NEW WELL E] DEEPEN C3RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑, OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR Qt <br /> REPLACEMENT r Pit Privy {r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines I <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> © INDUSTRIAL <br /> 11 CABLE TOOL. Dia. of Well Excavation <br /> IJ DOMESTIC/PRIVATE+ 13 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 /> 11 DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By <br /> 11 GEOPHYSICAL <br /> n & Irrigation,.- Inc <br /> PUMP INSTALLATION: Contractor . 2 <br /> Type of Pump- Myers submersible H.P. <br /> '4 <br /> PUMP REPLACEMENT: ❑ Stale Work`.Done <br /> PUMP REPAIR: <br /> 13 State Work Done - ; <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diametef.:_ _ <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordaoce with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San..Joaquin Local Health Di strict. <br /> I € : <br /> Home owner or licensed agent's signature cer[lTies the following:"I certify the performance of the forwhich this permit <br /> is issued, I shall not employ any person in such manner-as t -bedtime=subj�et to udorkman'scompensation laws of California." <br /> Contractor's hi 9q g or sub-contractingsignatyre certifies the following:"I certify that in the performance of the work for which this <br /> permit i i u I shall employ persons subject to workman's-compensation laws of California." <br /> [. <br /> I wil C ro Inspection prior to grouting Bnd a final inspect! n.` <br /> Tile: Date: <br /> Signed X <br /> (Draw,lot Plan on Reverse ide) <br /> FO DEPARTMENT USE ONLY <br /> _ �- 1/ � 7 <br /> PHASE 1Dale 7 <br /> „. <br /> it Application Accepted-By t i " t <br /> I Additional Comments: -� .� <br /> Phase Ill Final Inspe tion <br /> Phase 11 Grout Inspection <br /> 'Date �"°�-- Inspection By a .. ✓ <br /> Inspection By -te y w <br /> 31 ❑ July t &Received July 31 <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT � SITE'---PER S; E'- - ❑ EACH ❑ January l &Received By January REMIT <br /> BILLING '-� REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION HATE BATE REMITTED AMOUNT <br /> FEE 4 <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> p OTHER <br /> 1 Date Receipt No. P i N Issua ce Dat Mailed Delivered <br /> Received by <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE-,P.O.Box 2009 STOCKTON,CA 45 <br />