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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FQ1 OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> 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 San Joaquin Local Health District. <br /> Exact Site Address / Y19 G C City/Town <br /> Owner's Name _2.� Phone �* <br /> r Address ��44 ffy ft/?7--&&7 I�� ZZ-i � Y a�� City d <br /> Contractor's Name C It� WKYU ;4: rUJV `0t a�tc�c�:!�se# Business Phone <br /> Contractor's Address 2�z y yA/7 'f y `d} Emergency Phone t <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❑ �? <br /> REPLACEMENT❑ 44 <br /> t 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 R� <br /> f ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE El DRILLED Dia. of Well Casing -6 ~ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> F ❑ IRRIGATION ❑ GRAVEL{-PACK Depth of Grout Seal a �` <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout Gy 1r <br /> ❑ DISPOSAL _ ❑ OTHER ' Other Information <br /> ❑ GEOPHYSICAL „ ,, Surface.Seal Installed By: <br /> PUMP INSTALLATION: r Contractor <br /> % - r <br /> Type of Pump H,P. <br /> i PUMP REPLACEMENT-. ❑'State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> k <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 /> t ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work forwhich 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 <br /> I permit is issued shall emplo persons subject to workman's compensation laws of California." <br /> I all r Gr t i rior grouting and a final inspe i C �� r lC v_ ,C <br /> I Signed X Title: �"� Date: Z167/_ �4 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONL�I�"' <br /> PHASE I <br /> Application Accepted By =" " Date 29 <br /> tt Additional Comments: <br /> j Phase II Grout Inspection Phasielit al Inspection <br /> Inspection By Date 9 �� Inspection By Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED IlliAMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 3 � <br /> LESS <br /> P90RATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No I suance Date Mailed Delivered <br /> APPLICANT—RETURN.ALLCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box-2009 STOCKTON,GA 95201 <br />