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FOR OFFICE USE: ./a�,/G 25. � v � d PLICATION <br /> aon- ferable, Revocable, Suspendable) <br /> SAN JCA ENVIRONMENTAL HEALTH PERMIT PUMP&\NELL <br /> N' . <br /> (COMPLETE IN TRIPLICATE) tAQ11f <br /> LTh L)/SrpLO!�C,4t WATER QUALITY <br /> Application is hereby made to the San Joaquin Local&Qii District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulations of the Sar1Joaquin Local Health District. <br /> Exact Site Address �3ci � M1«A"')�iJ� SF` City/Town <br /> Owner's Name Ft'��"i�YYT cr l Phone <br /> Address —T City <br /> Contractor's NameLicense# us�in)ess Phone <br /> Contractor's Address ,o,'LhT �`� re,. Emergency Phone T ta <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes I No V <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONN❑ <br /> WELL CHLORINATION ElWELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION H®'r 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 /> rr INTENDED USE TYPE OF WELL ' <br /> 1 <br /> ❑�-I/IDUSTRIAL 11CABLE TOOL Dia.of Well Excavation <br /> o DOMESTIC/PRIVATE ❑ DRILLED Die. 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 �,f 16-1 <br /> W <br /> Type f Pump - H.P. <br /> PUMP REPLACEMENT: tate Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure =' <br /> vi <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Q <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. l <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 w for a Grout Ins actio or to routin ,and a final Inspectioft. <br /> Signed X Title: L///G � Date: <br /> (Draw Plot Plan on Reverse Bide) <br /> _ ORDARTMEN USE ONLY <br /> PHASE I �f <br /> Application Accepted By V ;2, Date 66 <br /> ) <br /> Additional Comments: <br /> Phase II Grout Inspection ha `J@�I��II��F"iingalllIIn�spection <br /> Inspection By Date Inspection ByI��J�2�� ! Da / i !/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ Jul eived By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT D CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> G <br /> 15 <br /> Received by Date ReceiOt No. Permd No. Issuance Date Mailed Delrvere0 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />