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r _ <br /> x Applications Will Be Processed When Submitted Properly Completed. Be ure oSign aApplication. <br /> 17 ` rJEFICE USE: APPLICATION <br /> _, <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> mittoconstructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora per <br /> made in compliance ' ! J�q County Or inance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ` City/Town -��s <br /> Owner's Name <br /> S ' III � 1111 ill'' Phone & Z 3 <br /> Address d6 � � City <br /> Contractor's Name �.L� K j+L f P License# Business Phone i <br /> Contractor's Address ZQ Emergency Phone <br /> 1 Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ S <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ d <br /> REPLACEMENT❑ I I <br /> DISTANCE TO NEAREST: Septic Tank Od Sewer Lines � Pit Privy <br /> Sewage Disposal Fiel1 Cesspool/Seepage Pit Other <br /> i <br /> Property Line ILV Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL Z r1 <br /> ❑ STRIAE ❑ CABLE TOOL `e Dia. of Well Excavation <br /> ❑ DRILLED 3 Dia. of Well Casing <br /> L� DOMESTIC/PRIVATE 4 t.� <br /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑, GWKeak <br /> EL PACK Depth of Grout S <br /> ( ❑ CATHODIC PROTECTION O RUT ARY Type of Grout _ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> i. ❑ GEOPHYSICAL Surface Seal Installed By: v <br /> PUMP INSTALLATION: Contractor rte' <br /> H. <br /> Type of Pump <br /> n <br /> PUMP REPLACEMENT: ❑ State Work Dane <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> t. DESTRUCTION OF WELL: Well Diameter PP p <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance witti San Joaquin County <br /> f ordinances, state laws, and rules and regulations'of the San Joaquin Local Health District. <br /> I Home owner or licensed agent's signature certifies the lollowingi"I certify that in the perfoemance of the work,forwhich this permit <br /> t <br /> t is issued, I shall not employ any person an such manner as'to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting'signature certifles the following:"I certify that in the performance of the ork for which this <br /> permit is issued, I shall employrpersons subject tooworkman's compensation laws of California.* 9 <br /> Ill call t ut Insppect' n prior to grouting and a final inspepcttion. _ <br /> Signed C Atli e r V. Date: � CULLY-2 A <br /> f .. <br /> 1 (Draw P(ot Plan of Reverse Slde) <br /> IIFF 9 FOR EPARTMENT USE ONLY <br /> I PHASE I 4�' Q �j . Y. <br /> Application Accepted Bye Date ! <br /> f <br /> Additional Comments: <br /> P ase II Grout Inspection t a ,F' ! Inspection <br /> Inspection By �'' <br /> Date T C3 $M1Inspecfion By ate / <br /> I Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El "❑ Januar ;1,&R�ved By January 31 ❑ July 1 &Received By July 31 <br /> . .^_ -' —� - Wil." <br /> BASE ExPLANATION BILLING �' REMITTANCE $ ' ' AMOUNT DUE CHECKED <br /> . DATE DATE ',�'.F REMITTED AMOUNT <br /> FEE °- <br /> ' LESS t - <br /> PRORATION <br /> PLUS <br /> PENALTY =t - <br /> OTHER <br /> - w_..,.w Jnr•.-.—�.,.-.....a.-w.w .�.—qua—"-�.r:...,...- rt <br /> OTHER <br /> le <br /> Received by Date Receipt No. Permit Na 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 />