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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) <br /> PUMP&WELL <br /> i ENVIRONMENTAL HEALTH PERMIT <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 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the SanJ aquin Local Health District. <br /> i Exact Site Address �r 4s 4 fly City/Town A-L-90 <br /> Owner's Name: - 'tPhone 3 <br /> Address City <br /> ca <br /> Contractor's Name��Ar tm^ I t icense#` 7� usinesspPhone <br /> I Contractor's Address mergency Phoneta �f 3 <br /> Is Certificate of Workman's Compensation Insurance on File With LHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTZI, z <br /> DISTANCE TO NEAREST: Septic Tank ��, " SewerL" es_�I1��-- Pit Privy C <br /> Sewage Disposal Field esspool/Seepage Pit Other <br /> Property Line 7v "t Private Domestic W II Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE POOL Dia. of Well Excavation <br /> 91--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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor1 <br /> Type of Pump Si!" An-e rt C-I H-P. <br /> PUMP REPLACEMENT: State Work Done Lo �✓ <br /> PUMP REPAIR: ❑ State Work Done I <br /> k DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 1 Describe Material and Procedure <br /> l -,. <br /> 4 _ <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 Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> k is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> C 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 /> F <br /> i I i11 call for a Grout Inspectio prior to groutin and 6 final inspectio . <br /> [ Signed X Title: Date: <br /> - (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> i; <br /> PHASEI 1. <br /> Application Accepted By _ <br /> Dates <br /> Additional'Comments: <br /> f <br /> Phase)l Grout Inspection Phase III Final Inspection <br /> a Inspection By Date Inspection By Date -' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By-January 31 ' ❑ July I &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> A AMOUNT <br /> FEE <br /> LESS <br /> r PRORATION: _ <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> Received by - Date Receipt No. W ii'ut Ro. IssuIlance ate Mailed - - Delivered - <br /> APPLICANT—RETURN.ALLCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> - .. —1-S <br />