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Applications Will BeProcessedWhen Submitted ProperlyCompleted BeSureToSignTheApplication rf5 <br /> FOR OFFICE USE: APPLICATION a � <br /> PUMP&WEf <br /> (For Non-Transferable, Revocable, Suspendable) urL �� <br /> L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Ale <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit toconstruct and/or install the work,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. r <br /> Exact Site Address `!� d - AJ City/Town A G.'a e-)Q 0 <br /> Owner's Name j"1"'Q It ACL i A t-vQ� Phone 3-3 CIL a/7�i-� <br /> Address 3.4 7 /�-/it/! P_k— r. City <br /> Contractor's Nam , 0✓J C 1'1 LJII Business Phone G 7 __ <br /> Contractor's Address.&_-I N' es/ M P-mergency Phone _9�'� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK,,(CHECK): ' NEW WELI.�-. DEEPEN ❑ RECONDITION,❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ 3 WELL. ABANDONMENT. OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑i <br /> DISTANCE TO NEAREST: Septic Tank A10A/t- Sewer Lines 1000-e- Pit Priv-y,,, /�AJG►N� <br /> /t <br /> Sewage Disposal Figld VAI e-- Cesspoow+ i/Seepage Pit a 4- Other 0x/ <br /> Property Lineal Private Domestic Well Public Domestic Well �N 1 <br /> INTENDED USE �^TYPE OF WELL <br /> ❑ INDUSTRIAL .kL 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 Q <br /> �r • <br /> 11 CATHODIC PROTECTION [1 ROTARY Type of Grout c rn-e R- <br /> ❑ DISPOSAL ❑ OTHER Other Information \ <br /> ❑ GEOPHYSICAL Surface Seal Installed <br /> PUMP INSTALLATION: Contractor �C .° P ✓� �' <br /> Type of Pump _ � -�i.��a . H.P. _ 1 4r 1 _ II <br /> PUMP REPLACEMENT: ❑ State Work Done g-: ------- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter- Approximate Depth / <br /> Desc ' e Material and Procedure - <br /> f U U e t. r <br /> I hereby certify that I have prepare' his-application and-lkat4ke worIl will be done in accordance h San Joaqu n County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's sibnature 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 certify that in the performance of the I work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I 1 call for a Gro spection rior tagrouting and a final inspection. { <br /> Signed X �� <br /> Title: Date' r -l / J <br /> (Draw Plot Pian on Reverse Side) <br /> 1 <br /> FOR DEPARTMENT USE ONLY i Q" <br /> PHASE I ;�`CJI <br /> Application Accepted By Date <br /> Additional Comments: <br /> = hase,11 rout Inspection / e III Final Inspection <br /> Inspection By Date i Inspection By Date <br /> Fee 1S DUB: ❑ ANNUALLY El PER UNIT ❑ PER SITE © EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> - --- REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT I <br /> FEE <br /> LESS <br /> PRORATION <br /> 3 <br /> PLUS <br /> PENALTY "t <br /> OTHER <br /> OTHER <br /> ece ed yDate Receipt No. Permit No Issuance Date Mailed Delivered <br /> App ANT—R201 <br /> ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />