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FOR OFFICE USE: APPLICATION Al <br /> Non-Transferable, Revocable,Suspendable) ,,"*4 PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> /^OMPLETE IN TRIPLICATE) WATER QUALITY <br /> )plication 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 h75a�JaDaOquin C•oAunty Ordini ce No.1862 and th u es and regulations of the San Joaquin LocaIM <br /> Health District. <br /> Exact Site Address /Y1 'zC t\ I�_( C `!Q X44 _5 � <br /> `, / City/Town <br /> II ,.vner's Name !T A t /� 6� Vii! LS Phone � <br /> RCdress — _ City ria A&& @AiS o <br /> I <br /> Contractor's Name 9:1 �5 License R��3�.(s 3 Business Phone �<!J'- r 3 Sl <br /> Infractor's Address/:) o ��r If!5 *4 /3 ASIZ Emergency Phone 7!kT- j3 V 7 <br /> .Certificate of Workman's Compensation Insurance on File With SJLHD? Yes tom' No <br /> TYPE OF WORK (CHECK): NEW WELLS— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> "'ELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION 0� PUMP REPAIR❑ <br /> PLACEMENT❑ <br /> [TISTANCE TO NEAREST: Septic Tank C3 Sewer Lines Ps QLS Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 7 Private Domestic Well Public Domestic Well <br /> r 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 5aX3 G <br /> fl CATHODIC PROTECTION RI-ROTARY Type of Grout / �i Ct\ t <br /> DISPOSAL ❑ OTHER Other Information <br /> !9 GEOPHYSICAL �y.� �.. Surface Seal Installed By: R'1 <br /> PUMP INSTALLATION: Contractor <Zim � S <br /> Type of Pump 'S c,Ls H.P. <br /> .IMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> -_STRUCTION 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 /> 9a. Home owner or licensed agent's signature certifies the following"Icertify that inthe performance of the work forwhich thispermit <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 will call for a Grout Inspection prior to grouting and a final inspection. `` n <br /> signed X V -i - Title: DateV <br /> (Draw Plot Plan on Reverse Side) G_J <br /> FOR DEPARTMENT USE ONLY \ <br /> PHASEI Gr�—l� e <br /> Application Accepted By %� <br /> Additional Comments: <br /> Of G t Inspectioni[,---�---� has 111 Final Inspection <br /> Inspection By _ Date X--� Wif Inspection By '� Date <br /> Fee IS Due: ❑ ANNUALLY ❑ EP R UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> y+ DATE DATE REMITTED AMOUNT <br /> PFF <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recervr��yyy-- I Dal - Receipt No, Permit No. Issuance Date Mailed Delivered <br /> LPPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.boa 2009 STOCKTON.CA 95MI <br />