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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> rcE USE: - APPLICATION <br /> (For Non-Transferable. Revocable, Suspendable) Cal <br /> PUMP&WELLI <br /> ENVIRONMENTAL HEALTH PERMIT Q <br /> "/_• r- I .7 <br /> ,,,,COMPLETE IN TRIPLICATE) ATER QUALITY I <br /> 'T Application is herebymadeto the n uin alalth istrictfora permit to construct and/or instal l the work herein described.This application is T' <br /> r. made in compliance ith San Jo uin County Ordinance No. 1862 and the rules and re ulations+of the Sa9LJoequin Local Health District.. t <br /> Exact Site Address!/ nl(r� _;` IA4 KIDI S ,,,&City/Town U TCf7 - <br /> Owners Name /G f / Phone a <br /> t Address city T, nampq <br /> Contractor's Name License N1'7- Business Phone Q�-OSa <br /> Contractor's Address Emergency Phone <br /> TIs Certificate of Workman's Compensation Insure cc on File With SJLHD? Yes No I..., <br /> TYPE OF WORK (CHECK): NEW WELL EP DEEPEN❑ RECONDITION❑ DESTRUCTION E3 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> �. REPLACEMENT❑ 4- 1 r <br /> `+' DISTANCE TO NEAREST: Septic TankSewer Lines'�f- : Pit Privy �"' — <br /> Sewage Disposal Field Cesspool/Seepage Pit /9&2.0 ' Other <br /> Property Line /$/ Private Domestic Well Public Domestic Well <br /> r INTENDED USE ,.. /TYPE OF WELL <br /> i ❑ 15RUSTRIAL I&'CABLE TOOL Die. of Well Excavation 42 <br /> ESTIC/PRIVATE ❑ DRILLED Die. of Well Casing ,p M <br /> 4, ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing z;2- S� <br /> 11 IRRIGATION - 13 GRAVEL PACK "� Depth of Grout Seal �b r - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - z re - - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> f PUMP INSTALLATION: Contractor <br /> + tType of Pump H.P. <br /> .. PUMP REPLACEMENT: "❑ State Work Done !w <br /> PUMP REPAIR: ❑ State Work Done <br /> f DESTRUCTION OF WELL: �'Well Diameter Approximate Depth <br /> )Describe Material and Procedure <br /> ! n <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ,: <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will II fora Grout Inape n D for to grouting and a final inspec 'on. <br /> I, <br /> { Signed Title: Date: 1-.QefJ& _ <br /> V 100F (Drew Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> i PHASE I J� <br /> Application Accepted By (� Date <br /> Additional Comments: <br /> P e 11 Gro lo.'pection / 7(t' P 111 Fina Inspection <br /> r Inspection By Date �/ r�$a Inspection By Date � O V <br /> Fee Is Due: EI ANNUALLY [3g PER UNIT i PER SITE ❑ F CH ❑ Jenuery 1 6 ReceNed By January 31 ❑ July i a Re.y d By July 31 <br /> REMIT <br /> j BILLING REM ITTANOE S <br /> TED <br /> SASE E%PLANATION DATE DATE REMITAMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> i LESS <br /> PRORATION <br /> V PLUS <br /> PENALTY <br /> 4011 OTHER <br /> OTHER IF 01 1 <br /> rju <br /> l Received by+ DOM • Receipt No. Perm, laeuence Dele. Miiu d Oelivemd <br /> + _ APPLICANT—RSTYRN ALL COPIER TO: •ENVIRONMENTAL HEALTH PERMIT/SaRYICEB //(� R MNLT9N AYj�l.F..O.aoz 2009 STOCKTON,CA%21h <br />