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..—Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ~F�.4.OFFICE <br /> USE: APPLICATION <br /> / <br /> (For Non-Transierable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> s" WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) - #00 <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is. <br /> made in compliance with San Joaquin County Ordinance No.18//62 an the rule and regulations of the San Joa_qu�i*n_I oc i Health District. <br /> Exact Site Address / �"3 ?�'1�.�'�n City/Town <br /> Owner's Name p76 A,r,47 Phone <br /> Address / 2_/ y� J2 City <br /> Contractor's Name Ilb License# t'y3_7Xr–Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes _ No <br /> TYPE'OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® 4. <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other A <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 N <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor e C� <br /> Type of Pump H.P._ G - 5 <br /> PUMP REPLACEMENT: ❑ State Work Done ? <br /> PUMP REPAIR: State Work Dane 0 <br /> DESTRUCTION OF WELL: Well Diameter '. Approximate Depth <br /> Describe Material and Procedure" <br /> 1 hereby certify-that I have prepared this application and that-the work will be done in accordance with Sart 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: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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." E <br /> I ill call for a Grout Inspectionpri r ting and a final inspection. <br /> Signed Jta Title: Date: <br /> (Drawt Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By 4,z,r Date 7. <br /> Additional Comments: I <br /> Phase fl Grout Inspection Phage 111 Final Inspection <br /> Inspection By Date Inspection By d�f ,,tDaa/]}7q <br /> r Fee Is Due: 13 ANNUALLY ❑ PER UNIT PER SITE 13 EACH El January 1 &Received By January 31" -�. July 1 &Received By July 31 <br /> BS- REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> D TE DATE REMITTED <br /> AMOUNT <br /> FEE 1 <br /> s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _. 11101 E.14AZELTON AVE.,.P.O.Box 2009 STOCKTON,CA 95201 <br />