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Applications Will Be Processed When Submitted Property Completed.'Be Sure To Sign The Application. <br /> -FOR OFFICE USE: APPLICATION <br />` < _ (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT. <br /> t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to c onstruc t and/or install the work herein described.This application is <br /> made in compliance with Sa-p Joaquin County Ordin nce No. 1862 and the rules and regulations of the San Joaquin Local Health District, W <br /> Exact Site Address ¢ °� `� ze f City/Town ,. <br /> Owner's Name —A: k- 'r, r l { - phone <br /> Address City <br /> Contractor's Name ,E C t. 311 4L it r +t7 License 4Zf4;16 Business Phone <br /> Contractor's Address ';Z P"t S�rr� y i•N: Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NO <br /> TYPE OF WORK (CHECK): NEW WELL 5t DEEPEN ❑ _REC_ONDITION❑ .. D.ESTRUCTIO,N Q <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r <br /> REPLACEMENT❑ I' <br /> DISTANCE TO NEAREST: Septic Tank 1,fi Sewer Lines ��d �'"°PitfPrivy <br /> Sewage Disposal-Field- - - --' Cesspool/Seepage-Pit -- --•-Other -- - -- <br /> Property Line . Private Domestic Well Public Domestic Well r <br /> INTENDED USE TYPE <br /> OF-WELL-INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ J f <br /> DOMESTIC/PRIVATE ❑ DRILLED t - i 1 pia. of Well Casing — ' <br /> DOMESTIC/PUBLIC ❑ DRIVEN 1 Gauge;of-Casirig <br /> ❑ IRRIGATION IN GRAVEL PACK Depth of Grout Seal 4a,4 <br /> ❑ CATHODIC PROTECTION =1 ROTARY Typ of Grout <br /> DISPOSAL ;❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:. <br /> PUMP INSTALLATION: Contractor t- ; <br /> Type of Pump 'H:P. <br /> PUMP REPLACEMENT: ^❑ State Work Done <br /> PUMP REPAIR: - ❑ State Work Done W <br /> DESTRUCTION OF WELL: Well Diameter 4 Approx"ate Depth <br /> Describe Material and Procedie <br /> I hereby certify that I have'prepared this application a6ldthat the work will be done in accordanbe with San Joaquin County <br /> ordinances, state laws, and:rLiles and regulations of the San Joaquin Local Health District. <br /> }tome owner 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 or sub{gontracting signature certifies the following:"I certify that in the performance of'the work for which this ; <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior,to grouting and a final inspection. <br /> ' <br /> Signed X r 1 r �r�, i' r # � Title: Y �`Y' 31 Date: <br /> " 'r (Draw Plot Plan on Reverse Side) <br /> L i <br /> IF FORIDEPARTMENT USE ONLY <br /> PHASEI t. <br /> Application Accepted By 04 �. ._ _ - oe Dat / <br /> Additional Comments: { <br /> Phase If rout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 13y July 31; <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKID <br /> DATE DATE REMITTED AMOUNT <br /> y f <br /> FEE v'I <br /> LESS I <br /> PRORATION - <br /> PLUS <br /> PENALTY --ti= <br /> OTHER <br /> OTHER <br /> 7q7/--)-3 <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> i .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 r <br />