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Applicatlons Will a�odessed WT n fitted Properly Completed.Be Sure To'Sign The Application. <br /> F 7R OFFICE USE: to -- V L PPLICATION <br /> or Non- rI era e, Revocable,Suspendable) PUMP&WELL <br /> DEC 14 11WIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) t WATER QUALITY <br /> Application is hereby made to theQfkkaauar(!L Gal ealftXst;ctfora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joagtk�LR-t�br5iinag-oeC or1852 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ///.34C so, ,fJf`7/cfs[i ,��{. City/Town e9 r,► ,9V,47IIZA4'-'� F <br /> Owner's Name - i�t'i✓ QCT!" T Phone 910 >-641F <br /> Address &�Mc; .6PC, City AIV22•t�f'd*j <br /> Contractor's Name 144 6-..._.lezee,1716License# 4 6f$'fie Business Phone X34 <br /> Contractor's Address - ����' -IT__ 04!art 4-616W Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File,With SJLHD? Yes No Q�1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ j <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR®� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank i 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 ❑ CABLE TOOL Dia. of Well Excavation <br /> ('DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION v ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Cl ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL i Surface Seal Installed By: ,- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: t ❑ State Work Done Q <br /> PUMP REPAIR: r tate Work Doneofelmk p! 4f A.d aL AW412"-f- UA./Z <br /> " DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> i <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 orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, IF shall employ persons§ubject to workman's compensation laws of California." *�r <br /> I will call for a Grout Inssppection.prior to grouting and a final inspection. <br /> Signed Xf ...t.- .Title:",k. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I IQ� <br /> Application Accepted By - �� __ jT7 Date/ <br /> Additional Comments: <br /> (Phase 11 Grout Inspection Ph se III Final Inspection <br /> Inspection By. Date inspection By Date �'Z' <br /> Fee Is Due: ❑- ANNUALLY ❑ PER UNIT ❑ PER SITE Cl EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - BILLING REMITTANCE REMIT <br /> - - $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - AMOUNT <br /> FEE <9 t4, <br /> LESS € <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - - - <br /> OTHER <br /> i Received by bate Receipt No.- - Permit No. Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />