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+ _ Appticatfons WIII Be Processed When Submitted Properly Com leted. Be Sure To Sign The A <br /> Fi�R OFFICE USE: APPLICATION g pplfcattfon.- <br /> T,� . <br /> ;may <br /> a (For Non-Transferable, Revocable, SUspendable) <br /> Ir , <br /> L ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) <br /> 4pplication is herebymade to th L WATER QUALITY <br /> eSanJoaquinLocalHealthDistnctforaPermittoconstructand/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San J <br /> Exact Site Address��9f _ f6f/�y pp Joaquin Local Health District- <br /> Exact <br /> / ---- <br /> Owner's Name City/Town <br /> _��G_ ?���Sf <br /> 3 Address /$^ �W `- Phone 3 3¢- 3 <br /> c Contractor's Name I City S <br /> "r �� <br /> Contractor's Address � _ � - License ff -:,— �--mousiness Rhone 7 <br /> Emergency Phone _ �dz�_ �rs <br /> Is Certificate of Workman's Compensation Insurance on File ith SJ HD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ No <br /> DEEPEN ❑ RECON0 TION DESTRUCTION❑ <br /> WELL C LENT 0 ION ❑ WELL ABANDONMENT❑ OTHER D PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLAC MENT❑ � �' <br /> DfSTANC TO NEAREST: Septic Tank <br /> -.L�•Q.� Sewer Lines �p � Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Pro ert Line t— Other — — <br /> P Y _Private Domestic Well Public Domestic Well <br /> INTE DED USE TYPE OF WELL <br /> ❑ INDU RIAL �� � <br /> CABLE TOOL Dia. of Well Excavation <br /> ❑ DOME TIC/PRIVATE ❑ DRILLED <br /> Dia. of Well Casing .T/.f/� /e'Z/r �,n., /19" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> n Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal /L/dsts@ <br /> ❑ CATH IDIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPO 3AL ❑ OTHER -- — <br /> Other Information <br /> ❑ GEOP YSICAL ce Seal 1 talled By: _ e�,Y/XT/.(/L'S <br /> PUMP INS ALLATION: Contractor_ 4 _ <br /> Type of Pump. _ IF H.P. OQ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: N ❑ State Work Oone_ <br /> ESTRUC ION OF"WELL: Well Diameter _ Approximate Depth <br /> i� Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> rdinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> ome owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> s issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California." { <br /> ontractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> rmit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> will all for a r Ut nspection prior to grouting and a final inspection. <br /> ,�-- <br /> Sigma X Title: _`d7UlJL�Jd� -� _ _ -Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHA EI / <br /> Appli ation Accepted <br /> Addi oval Comments: a�+ sh germ Date <br /> __ a <br /> Phase it rut l;;;—tion T III Final Inspection t }-� # <br /> I spection ByNA Date- Inspection 8y Q$te �1�L <br /> (1� 1 r <br /> Fee I DUO:-❑ ANNUALLY ❑PER UNIT ❑ PER SITE ❑ EACH ❑ January 18 Rece;ved By anuary 31 ❑ July 1• ecerved ey July 31 <br /> BILLING REMITTANCE b REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE iQ�� <br /> LESS <br /> PROR TION 1 t <br /> PLUS <br /> PENAL Y ! 3 <br /> OTHER 1 <br /> OTHE '1 <br /> RemiVo by Date Receipt No. r'erm;t No. fssuancefDatel. Mailed oativem—o <br /> APP!CANT—RETUIIN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16011 E.HAZELTON AVE.,P"O.Box 2009 9TOCKTON:CA-9s2o1, ' r <br />