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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign''The Application. <br /> FOR OFFICE USE; APPLICATION <br /> r �Jn /�r�� (For Non-Transferable, Revocable,Suspendable) to <br /> PUMP&WELL ���/// <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r 'AWA E UALITY d <br /> (COMPLETE IN TRIPLICATE) � GQp'7 �.. gt.ZZ AER, Z7O <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 Or finance No.1862 and the rullss and Ovulations of the Sa Joaquin Lroc�I Health District. <br /> Exact Site Address moXA—Ala/I.Som 0-k u"40; - a kl �,V0e&ems ._City/Tower iiie� <br /> Owner's Name rt f? Gr Phone <br /> Address �� �u !12 a <br /> Contractor's NameLicense #11--19 Business Phone 2a — � Off. <br /> Contractor's Address ` Emergency Phone C <br /> Is Certificate of Workman's Compensation In ranee on Fif ith SJLHD? Yes�X _ No } <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN'❑ RECONDITION❑ DESTRUCTION❑ 5 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 4 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 f " <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal In alled By: y 1 <br /> PUMP INSTALLATION: Contractor tom.. <br /> Type of Pump t o a/ H.P. V-0 <br /> PUMP REPLACEMENT: ❑ State Work DoneAL <br /> PUMP REPAIR: State Work Done ���+� ,,d �. <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 /> Home owner 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 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 /> 141 call for a Grout Ins n or uting and a final inspection. <br /> Signed Title: Date: ! <br /> (Draw PIY Plan on Reverse Side) d <br /> ORD PARTME T USE ONLY 1 <br /> PHASE <br /> Application Accepted By /y I^'"` Date �a <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE' - ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT OUE ' CHECKED <br /> DATE - DAT' REMITTED AMOUNT <br /> FEE r <br /> w <br /> LESS C U s <br /> _ PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> Received by Date Receipt ND. Permit No Issuan a Date Mailed Delivered <br /> ��' -<APPLICANT—RETURN ALL COPIES TO:a, ENVIRONMENTAL HEALTH PERMITISERVI CES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />