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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. A& Aft / <br /> F9R OFFICE USE: _ APPLICATION <br /> �w 16.. (For Non-Transferable, Revocable, Suspendable) I <br /> C6� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY Q <br /> Application i s he reby m ade to the San J oaq ui n Local Heal th District f o r a permit toconstruct and/or install the work herein described.This application ye is <br /> � <br /> made in compliance with San Joaquin County Ordinance No. 1862 end the rules and regulations of the San Joaquin ocal Ith District. <br /> Exact Site Address a"trCa �•," City/Town <br /> Owner's Name' t�a R AV k zo -Z-6 Phone <br /> Address `�`.o W u ►�� — S� City <br /> Contractor's Name ��� � 4A f'. � License# 0.37��Business Phone 'Y <br /> Contractor's AddressEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With LHDI Yes_.- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ AECONDITI ON❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR f <br /> 1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br />! Sewage Disposal Field Cesspool/Seepage Pit Other <br /> E 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 y ❑ GRAVEL_ PACK Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL_ ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 77f H.P. a <br /> PUMP REPLACEMENT: a ❑ State Work Done <br /> PUMP REPAIR: State Work Done tj.4c�C G.� e/Jl dow '1 ! <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L a <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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." I <br /> I I call for a Grout Insp ion p 'o gr ing and a final inspection. <br /> i <br /> Signed Title: �"�:d _ Dale: 1 <br /> i (Draw Plo Ian on Reverse Side) <br /> I <br /> + FOR EPARTMENT USE ONLY <br /> PHASE I �+• � <br /> i Application Accepted By. _�_ - Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> 4 b ' <br /> 1 Fee IS Due: ❑ ANNUALLY ❑ PER UNIT IDI PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i REMIT <br /> BASE EXPLANATION - BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE4/ - <br /> LESS _ <br /> PRORATION f <br /> PLUS I <br /> PENALTY <br /> i <br /> OTHER w <br /> t ,_ OTHER <br /> L Received by Date Receipt No. Permit No. ! Issuance Date .. Mailed Delivered <br /> I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES . 1601 E.HAZELTON AVE.,R.O.Box 2009 STOCKTON,CA 95201- <br />