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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FORffFICE USE: APPLICATION J <br /> r (For Non-Transferable, Revocable,Suspendable) p <br /> .1 ._ PUMP&WELL t <br /> ENVIRONMENTAL`AEALTH PERMIT �J <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is U1 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address `4e IV+_ C64Ze4V gprCity/Town GQ®j <br /> Owner's Name Phone <br /> Address City— <br /> Contractor's <br /> ity Contractor's Name License#�3 �9 Z­Business Phone ' <br /> I Contractor's Address "FD eox _S c4e4c- i5- Emergency Phone <br /> C� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes— - No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0 PUMP REPAIR❑ <br /> REPLACEMENT❑ ft <br /> DISTANCE TO NEAREST: Septic Tank 5 Sewer Lines -7 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 fir F14-5 7— f <br /> DOMESTIC/PRIVATE ❑ DRILLED A Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing l� s <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 4 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �+� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 611_4W4A( rQ�cCGl�fC�i <br /> ' PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> j PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 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 /> Home 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-contracting signature certifies the following:"i certify that in the performance of the work forwhich 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 /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By a`^ Date <br /> Additional Comments: <br /> Phase II Grout Inspe lion / Ph as III Final Ins p ction <br /> Inspection By Date—/II GL) /rte 7 Inspection By ate �,J �,�� 7 P <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31. <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION ED <br /> DATE DATE REMITTED I AMOUNT . <br /> FEE � 4_ <br /> � Y � <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER <br /> . OTHER <br /> [Received by Date Receipt No. Permk No. - Issuance Date - Mailed Delivered Cv—Sri l <br /> •" <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16D1 E."HAZELTON AVE.,P.O.Bax 2009. STpCKTON,CA 95201 <br />