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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ' (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER r <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 <br /> ade in compliance wit San�Jtoaa - C u?nty Ordinance No. 1862 and the rules and regulationsof the San Joaquiin,L�cal Health District. <br /> Exact Site Address �O.i )�1 Gc t�s�D City/Town <br /> Owner's Name E Int 9L " •,A �st� 5 adz Phone!�•C --- <br /> Address W City !lzf' <br /> Contractor's Name '� License,# "' - Business Phone'- <br /> Contractor's Address I' Emergency-Phone ' F <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❑ PUMP REPAIR❑ CIS) <br /> REPLACEMENT❑ \ 'j <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION _ ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 13 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑ State Work Dane <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTIO ELL: Well DiameterApproximate Depth <br /> Describe Material and Procedure <br /> • " - - X11 C,�.,�-cH,�4�.�s✓tl�s: - <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 /> .f <br /> Homeowner or licensed agent's signature certifies the following:1 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 l <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t I� call for a Grout Inspection prior to grouting-and a final inspection. <br /> i <br /> Signed X i -+D�f+ +� Title: ���r` ' Date: Glu <br /> (Draw.Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY t <br /> ' PHASE I - <br /> o <br /> Application Accepted By Date <br /> Additional Comments. <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection Bt'-_?&yDate 6b12 Inspection By, - Date <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 /> iBASE EXPLANATION - BILLING REMITTANCE- 3 $ AMOUNT DUE CHECKED- <br /> DATE DATE- REMITTED' AMOUNT <br /> FEE <br /> LESS CSL <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> IZL <br /> Received by ate- --- Receipt No - - Permit No. - - Issu nee Dfb -- Mailed _ Delivered:-- ' <br /> APPI-CA T—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo:2009 STOCKTON,CA 95201 _f <br />