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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFEICE USE: APPLICATION <br /> •" (For Non-Transferable, Revocable,'Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> fl <br /> M1 COMPLETE IN TRIPLICATE} WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San.,Joaquin Cp_uunty Ordinance No. 1862 and the rules and regulations of the San Jo a uln Local Health District. <br /> J. <br /> Exact Site Address �� / lfa III <br /> 3.4 City/Town <br /> Owner's Namel Phone <br /> r _ Address �srr, '' f City. PCZ Cil ', <br /> Contractor's Name IWR- r ' r�1 H9 4. "License#�L-_ Business Phoned <br /> f Contractor's Address 0 0, r t .4 'Emergency Phone } <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yesa No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ T RECONDITION❑ DESTRUCTION❑WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> ! REPLACEMENT❑ <br /> i DISTANCE TO NEAREST: Septic Tank __(fly Sewer Lines a � Pit Privy �— <br /> Sewage Disposal Field- Lct7- -- Cesspool/Seepage Pit "'— Other <br /> s: Property Line Private Domestic Well Public Domestic Well <br /> r INTENDED USE TYPE OF WELL <br /> I. w <br /> r ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation -' r - - <br /> XQOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing x <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN —Gauge of Casing f <br /> ❑ IRRIGATION RAVEL PACK I Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY "Type of Grout .Oht r .X-P <br /> ❑ DISPOSAL ❑.OTHER Other Information i f �l 49ir . ata a yi�­ <br /> ❑ GEOPHYSICAL "'� y Surface Seal Installed By: _ 6�&o r' <br /> PUMP INSTALLATION: Contractor <br /> .r <br /> Type of Pump H.P. '„ <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> DescribeMaterialand 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:"I certify that in the performance of the work forwhich 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,') shall employ persons subject to workman's compensation laws of California." <br /> .—I will call fora Grout Inspection prior to grouting and a final inspection. F <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> r T <br /> FO DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted'By / Date <br /> x Additional Comments: F <br /> Ph a a II Grout Inspection Phase II Final Inspection <br /> Inspection By - f '�3'"'_: Date 1 ! Inspection By A Date - - <br /> I . <br /> f ; <br /> [E Fee IS DUe: ❑ ANNUALLY' PER UNIT PER SITE EACH. ❑ January 1 8 Received By January 31 ' [3 July 1-&Received lay July 37 <br /> REMIT <br /> -BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT pUE CHECKED <br /> } _ DATE DATE REMITTED AMOUNT <br /> FEE ,t <br /> LESS <br /> PRORATION �� } <br /> ' PLUS ; . .. <br /> PENALTY' f <br /> OTHER <br /> OTHER ; <br /> - S P ?/ <br /> Received by Date Receipt No -' - Permit No.- 1 Iss ante Date. - Mailed. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,.P.O.Box 2009 STOCKTON,CA 95291 <br />