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FOR OFFICE USE: APPLICATION <br /> or Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT A ,� � �NS�• <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with S do Joaquin County Or mance No.1862 and th rules and regulations of the San Jo quin Local Health District. <br /> Exact Site Address��VC& ��� ��R'A� � City/Town GCA m�P I <br /> Owner's Namie�' F 14R_MA I,,) Phone 36 y'- 3/6 <br /> Address alb tg - City <br /> Contractor's Name ��LI/�''p a,4a f,/i c� Ld.-�� ORi��iwdQ119�e# .?J/T/23 Business Phone 6,1 7 r <br /> Contractors Address e(eri /✓I �OM ZZ,e• �� H�alSE9qy Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? rEes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ �/t '�J Noa� <br /> DISTANCE TO NEAREST: Septic Tank /Jew Sewer Lines 1U0,i Pit Privy ' l <br /> Sewage Disposal Fief Cesspool/Seepage Pit AJ0"C _ Other A d Ou It— p <br /> Property Line Private Domestic Well AJOI/a-PubliC Domestic Well lV d w1<--- <br /> INTENDED USE TYPE OF WELL /4 "/ G <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation J <br /> 1OMESTIC/PRIVATE DRILLED D . 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 Q r'''!A✓f - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALurface'Seal Installed B X21 <br /> PUMP INSTALLATION: Contractor 1 1 f I aJ 4 — <br /> Type of Pump . 1^ryvwy-a r H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done - <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 subcontracting 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 call fora <br /> Gro ul s tl n pN r to groutin and a final Inspection. <br /> Signed X � ��-'� _ Title: L. �i Data: ��1 �' — 7 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPART ENT USE ONLY <br /> PHASEI <br /> Application Accepted By M'V'^ Date ?� <br /> Additional Comments: <br /> Phase 11 Grout Inspection - Phase III Final inspection <br /> Inspection By .Date 9�1 9 Inspection ByPJ�yp,,i /40 Li 2 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 a Received By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT/ <br /> FEELESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER q <br /> Received by Data Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 18111 E.HAZELTON AVE.,P.O.boa 2008 STOCKTON,CA 95201 <br />