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Applications Will Be Processed When Submitted Properly Completed. Be Pr d'sig 1he ication. _ <br /> FOR OFFICE USE: APPLICATION ' ;, j V ��� 3 , 91 <br /> I {For Non-Transferable, Revocab s 4' � IW <br /> t ENVIRONMENTAL HEAL ERM PUMP&WELL <br /> M (COMPLETE IN TRIPLICATE) WATER QUALITY } <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and!o1�yrinstgtl�e�ntrl�k e4 described.This application is <br /> made in compliance with San Joagg��ui�q County Ordinance No. 1862 and the rules and regueNq t#x 1 lit <br /> uin Local Health District, <br /> Exact Site Address 1�11 /c/4& Xd. / own i,07� <br /> Owner's Name / Phone J9F.7 3 5—? <br /> Address [.p fig}o I N. :- �u i��.. City L de{rr o4 <br /> Contractor's Name PLL PI�Avt4LP. �#J1e1/S r a'jlhG License 4-377 3 Business Phone 13/^ q J469 t <br /> Contractor's Address "T'�h�'� Emergency Phone 1', <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ LD <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ -PUMP INSTALLATION 9 PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> s <br /> Sewage Disposal Field Cesspool/Seepage Pit Other r <br /> -Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 4 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ` ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _01- <br /> El <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER �O her Information <br /> ❑ GEOPHYSICAL. _ ;,, ___'77Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r1LY✓f-t"A-p. _ �Y' �C',YS I C to C(.0 rip, <br /> Type of Pump Sk�j e-.vc H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done c -A!47 <br /> DESTRUCTION OF WELL: lWell Diameter Approximate Depth <br /> Describe Material and Procedure-- P� <br /> 1 - <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-Ebcai Health District. -- <br /> Homeowner or licensed agent's signature certifies the following:"I certify-that in the performance of the work for which this permit <br /> l 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 subcontracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, k shall employ persons subject to workman's compensation-laws of California." <br /> I will call for -G ut spection prior-to grouting and a final inspection. - Y <br /> GO Pr s.f� <br /> Signed X. -Title: e.;.�.. �.,-=r.-.:: ...,.Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I pp���� <br /> Application Accepted By CO` Datel <br /> Additional Comments: <br /> Phase Grout Inspection PNM <br /> pection <br /> t. Inspection By Date Inspection By Date <br /> Fee IS Due: El ANNUALLY ❑ PERIUNIT ❑ PER SITE ❑ EACH ❑-January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> t BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED ' <br /> DATE DATE REMITTED AMOUNT <br /> FEE S' ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r OTHER <br /> OTHER f <br /> y Received by Date iReceipt No. Permit No, IsstiancefDate, Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMITlSERVICES `1 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />