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Applications Will Be Processed When Submitted Properly Completed. Be Sure- i�1T *NPI It�n"' <br /> FOR OFFICE USE: APPLICATION h �V1 Iii. <br /> (For Non-Transferable,'Revocable,Suspendable) PUMP&WELL <br /> dp ENVIRONMENTAL HEALTH PERMITtU 19$1 <br /> (COMPLETE IN TRIPLICATE) WATER,QUALITY <br /> ,-j i'�� f'r'4 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the haIigiA Q61Jc' lbe6f:fQkpplication is <br /> made in compliance with San Joaquin County Ordinance No. 188 and the rules nd.regula' ns of the San�J�aq�'W69cr WbTAIt9JUtrict. <br /> Exact Site Address I�f' � 0' ity/Town G� <br /> Owner's Name Phone <br /> t Address �A, ..» /,: City r f_: <br /> Contractor's Name fl LL" pr, P l i�w.R� License# Business Phone �� of �S 1.16 <br /> Contractor's Address ) % 2 r- Emergency Phone 1 <br /> Is Certificate of Workman's_Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL_❑ 'DEEPEN ❑ RECONDITION❑ — DESTRUCTION d <br /> WELL CHLORINATION ❑- WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION d' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1 H.P. p <br /> PUMP REPLACEMENT: 199 <br /> State Work Done ,, 21�1 D X7,0.1 OqE_� <br /> PUMP REPAIR: ❑ State Work Done - On <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 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 /> i I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X IS�,c v7 �3� n n, r E,� Title: -I Date: <br /> rt. w t (Draw Plot Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY t <br /> PHASEI 1 <br /> Application Accepted By f ' � r —C"- Date <br /> Additional Comments: <br /> Phase I Grout Inspectionhas Ill Final Inspection <br /> Inspection By Date Inspection By Date AX) € <br /> i:- <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January S &Received By January 31 ❑ July-1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE c <br /> Q s <br /> i LESS , <br /> PRORATION <br /> PLUS t - <br /> PENALTY <br /> OTHER . <br /> L S <br /> OTHER y. <br /> Received by Date Receipt No.L Permit No. lisuanct Dae Mailed - Defivered� <br /> -� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 .ST6CKTON,CA 95201 �� <br />