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_ <br /> Apphca ions Will Be Processed When Submitted Properly Completed. Be Sure oSign a pp <br /> FOR OFFICE.USE: £ �", ,� :- -.'"'-APPL'1CATIQ.N <br /> �� At <br /> a i - (F_or_Non-Transferable;Revocable, Suspendable) PUMP&WI=LL <br /> -ENVIRONMENTAL.HEALTH PERMIT r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Applicationis hereby madetothe San Joaquin Local Health Districtforapermittoconstruct and/or install thew ork herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No 1862 and the rules and regulations f the San J aquin Local Health District- <br /> i <br /> Exact Site Address r G - f n 'd`� f, <br /> ,f� Phone <br /> Owner s - <br /> 4Name /, ewt� <br /> 15 1763 E. �/r�V1.e City_ �l. l� _X I <br /> Address ' _ License * / Business Phone <br /> �� <br /> Contractors Name <br /> 7 <br /> Contractor's Address f�� _� �� 61&.5 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes x No ! <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION 13 <br /> WELL CHLORINATION ElWELL ABANDONMENT 13OTHER El PUMP" INSTALLATION ❑ PUMP REPAIR❑ ` <br /> REPLACEMENT❑ �J <br /> DISTANCE TO NEAREST: Septic Tank. Sewer Lines Pit Privy <br /> Sewage Disposal Field r300 " Cesspool/Seepage Pit Other <br /> kProperty Line Private Domestic Well Public Domestic Well <br /> t INTENDED USE TYPE OF WELL Aad <br /> I ❑ CABLE TOOL Dia. of Well Excavation <br /> El '- �� YL► <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 Ah <br /> 1-1 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> FType of Pump H.P. <br /> k PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 10escribe Material and Procedure <br /> k 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:"l certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wit call fora Grout Ins ection prior to grouting and a final inspection. <br /> Signed X I f Title: Date: <br /> (Waw Plot Plan on 4,,.rsde) <br /> y FOR DEPARTMENT USE ONLY <br /> PHASE l i`"cc'— O 'e�7 Y <br /> i <br /> Application Accepted By—� Date <br /> Additional Comments: <br /> P ase I Grou Inspection Phase III Final Inspection _ <br /> Inspection By /�7�-�aatt�e Inspection By g` Date <br /> Fee ISS Due: ❑ NNUA PER UNIh� ❑ PER SITE El EACH ❑ January 1 &Received By January 31 I� July 1 &ReceivedREMITu y 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> t <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> r PRORATION <br /> I PLUS <br /> PENALTY - <br /> } OTHER <br /> OTHER <br /> rp <br /> Received by Date - Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO0CKTON,CA 95201 <br />