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Applications Will Be Procei-ssed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> FOFj OFFICE USE I' APPLICATION <br /> +� (For Non-Transferable, Revocabie,,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL +� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for apermit toconstruct and/or install the work herein described.This application is S <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 rGc (i A(Jre jpe ra City/TownC��-Jca , <br /> Owner's Name ON �/Alk f`1`o cv k pc Y�r . lost/ �ye/�a vlu r/d <br /> Address S o L �/ /! , Phone <br /> a City b4h,19A4A, x4tna5 u d; <br /> Contractor's Name Al 4_5 License# Business Phone S'99-3 ges'r- <br /> Contractor's Address . a1� C%. /1 eL i.y 11 -1�%P�J Emergency Phone 533 -39C.5-4 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 7< No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION � PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: -SepticlTank <br /> liSewer Lines - '`p-_ ` -Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Welles -Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL _ , ,, ..Dia:_of Weli.Excavation r <br /> DOMESTIC/PRIVATE 11 DRILLED Dia, of Well Casing 'r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing V d <br /> ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information Q + <br /> ❑ GEOPHYSICAL Surface Seal Installed By: I! <br /> PUMP INSTALLATION; Contractor /V"-5 <br /> Type of Pump ,v-S, 6/ H.P. l l2,- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shall not empiloy 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." 1 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X -Title: - - Date:. �- <br /> I� (Draw Plot Plan on ReverseAide) <br /> EPA MENT SE ONLY <br /> PRASE I <br /> J I <br /> Application Accepted By r Date <br /> Additional Comments:- <br /> Phase <br /> omments:Phase II Grout Inspection r Phase III Final Inspection <br /> Inspection By Date1' <br /> Inspection By Date � <br /> k `y <br /> Fee IS Due: ❑ ANNUALLY ❑—PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE <br /> BILLING REMITTANCE REMIT <br /> ry� EXPLANATION $ AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED <br /> }� �/` AMOUNT <br /> FEE 'r,�f f I p .(�.G�' vk_ <br /> LESS y <br /> PRORATION �. <br /> PLUS <br /> PENALTY .I�! <br /> OTHER <br /> OTHER "yD <br /> Received `, Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES ro! ENVIRONMENTAL HEALTH PER MIT/SEAVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />