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Applications Will Be Processed When Submitted ProperlyCompleted. Be SureTosign Tne,appucanon <br /> FOR OFFICE USE: APPLICATION i <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)gzWLf /J- `s'% cl✓ 7�� WATER QUALITY A4,J J Ln0-3 <br /> Appl ication is hereby madetothe San Joaquin Local Health 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. 862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �k �• yrlof: �r ,&G c ,sl, ✓f ,Tr, City/Town <br /> Tc,i,-% kcl, <br /> /� <br /> Owner's Name !'I-f-, ki &0165 Phone g %� <br /> Address ' �"�- Tori �1�� City <br /> Contractor's Name P.Uryiance Drillers Drilling Corp. License#22212-3 Business Phone ?�` 4/V <br /> Contractor's Address ' 6`1 rr /F.r Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 41-, No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITIONK DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 9 CABLE TOOL Dia. of Well Excavation y <br /> 181 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 0 3 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information f ~ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r1�� <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 /> Homeowner or licensed agent's signature certifies the following:A 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 shy employ persons subject to workman's compensation laws of California." <br /> I will call for ar rout In ection prior to grouting and a final inspection. <br /> Signed X �_ �,.f6 Title: Pr C_ /tJc--R Date: <br /> ! f (Draw Plat Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY gc <br /> PHASE I �.pate � <br /> 4 <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By_,j ate Inspection By Date <br /> Fee IS Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by to Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI$ERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> M <br />