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Applications Will Be Processed When SubmittedProperly Complete�� b7 isosrsInLaneJ%PR1itll <br /> .R OFFICE USE: APPLICATION 1 �J <br /> (For Non-Transferable, Revocable,Suspen le) �� 9O l <br /> 1. �- I IO PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY n <br /> COMPLETE IN TRIPLICATE <br /> Application is hereby made tothe San Joaquin Local Health District for a permit to construct and/or ih kuhee vtrPr$ lier:,6"n!drescribed.This application is <br /> made in cornpliancP�wi San J a uin County Or ante No 62 and the rules and.regulations of the San..fpap�liry, ca Health District. <br /> Exact Site Address � ?2.�/lJ ��• City/Town � <br /> ae <br /> Owner's Name s Phone t7a t�, 0 a ' <br /> Address — r lT 1 City <br /> Contractor's Name 7,79 s License �3 Busines Phone <br /> Contractor's Address Emergency Phone J l <br /> Is Certificate of Workman's Compensation Insuranc on File With SJLHD? Yes L-- No I� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ R_ECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION M-" PUMP REPAIR❑ <br /> REPLACEMENT❑ e <br /> DISTANCE TO NEAREST: Septic-Tank Sewer Lines! Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 1k Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE - TYPE OF WELL <br /> 13DUSTRIAL; ❑ CABLE TOOL Dia. of Well Excavation <br /> D DRILLED ESTIC/PRIVATE r'' t �� ❑ Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑DRIVEN Gauge of Casing <br /> ❑ iRRIGATION` ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY r Type of Grout <br /> 13 DISPOSAL .❑ OTHER ( Other information <br /> ❑ GEOPHYSICAL r` k- Surface Seal,-Installed By: <br /> PUMP INSTALLATION: Contractor a ti. ` ' <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: tate Work Don Aiol <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure , <br />, r <br /> I hereby certify that I have preps-red 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 /> Conlractor' firing or sub-contracting signature certifies the following ertify that in the performance of the work forwhich this <br /> Pi i sued, ! shall p persons subject to workman's com atkon laws of California." <br /> I w r rout s ecti n prior to grouting and a finAReverse <br /> . <br /> Signed X TiDate: <br /> L (Draw Plot PlanSide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By 0 Date <br /> Additional Comments: <br /> A� <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 0T) <br /> FEE <br /> LESS a� ' <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> _ OTHER <br /> OTHER <br /> 'Received by Date Receipt No. Permit No. —r._. I uance ate Mailed Delivered <br /> ti APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AYE.,P.O_Box 2009 STOCKTON,CA"95201 <br />