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FOR OFFICE USE: APPLICATION IL..3 tS <br /> (For Non-Transferable, Revocable,Suspendable) JAN 2 <br /> --�-- <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> COMPLETE IN TRIPLICATE) WATER QUALITY ny`;i� E Ir "J_,.Rti'T <br /> lP,ppl ication 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 Jo quijp �Cou y Ordinance No. 1862 and the rules and regulations of the San Joa n Lo I,IH--eal h District. <br /> ` xact Site Address Z 1 C=� A City/Town <br /> cny <br /> wrier', Name r Phone <br /> Address - ^4.. `� _ City )'Yta etc ti. G!� <br /> :ontractor's Name - �94711 IC�Awfnll License#2,kAAJ�6 Business Phone R2 <br /> �:.ontractor's Address I G: - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes It/ No <br /> --YPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> YELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> 'REPLACEMENT❑ <br /> INSTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Ilia Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 1 _:1 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 4Nr� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 'Ii��� CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> 'LJ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor A:4- (–�e f otT, <br /> I.. Type of Pump Imo-- H.P. <br /> PUMP REPLACEMENT: IXi State Work Done !FjwL", A&Vpo�As.0 ,.Ljd u . <br /> 'UMP REPAIR: ❑ State Work Done <br /> )ESTRUCTION 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 Q_ <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1,01 call for a Grout I/5SP_"ition prior to grouting and a final inspection. J <br /> _Signed X � ^.]a1'+�.R-- Title: -aw--..: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> 1 1� j(\1 la <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection n Phase III Final Inspection <br /> Inspection By — Date Inspection By_. 1f__M_,.� Dateq_TT "1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received,By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASEEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> (I � J <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> (Y) <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 9s <br />