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Applications Will Be Processed When Submitted Properly Compl tel B LI&&USSVheAA#pI�I n. <br /> = FOR gFF{CE USE: � APPLICATION !!�� <br /> (For Non-Transferable, Revocable, S ableaj 26 1981 <br /> JJ tt PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> WATER.QUALITY SAN .f')^;QU'N L_O�AL <br /> [COMPLETE IN TRIPLICATE} � IIS�II p��'F�.� <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/c t JJ�I w9ik �9Aadescribed.This application is.,,, <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San�,loaquin Local Health District. <br /> Exact Site Address (� 11 f Qit� City/Town J�o�[ZT��L <br /> Owner's Name Phone <br /> Address City �6—_71 <br /> Contractor's Name —1 License# Business Phone 4—�22 <br /> Contractor's Addressh Emergency Phone (. I <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 13 WELL ABANDONMENT El OTHER 13 PUMP INSTALLATION C1 PUMP REPAIR❑ r <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy p(5 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 0 <br /> Property Line Private Domestic Well Public Domestic Wel <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 1:1 CABLE TOOL pia. 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 /> 13 CATHODIC PROTECTION i E] ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information a( <br /> ❑ GEOPHYSICAL I Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ (✓ <br /> f <br /> Type of Pump �" H.P. <br /> , <br /> PUMP REPLACEMENT: t� State Work Donee-� <br /> PUMP REPAIR: ❑ State Work Done V <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 law0and 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 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 Ji <br /> It is iss ed, I--shall employ rsons su ject to rkman's compensation laws of California." <br /> i� ,M <br /> pe <br /> I will cal or a Gro lupe prior t grouti nd a final inspection. <br /> ,i <br /> Signed X .L Title: Date: <br /> I� (Draw lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> &%A-, <br /> Application Accepted By "" Dale <br /> Additional Comments: <br /> Phase II Grout Inspection Phase ill Final Inspection <br /> Inspection By A N. I, Date spection By ?$"< Cz� Date <br /> Fee Is Due: ❑ ANNUALLY '.r.I' [I PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ' <br /> REMIT <br /> BILLING REMITTANCE $t, II <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> I. DATE DATE REMITTED AMOUNT <br /> FEE I rl <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> 'OTHER <br /> III i <br /> b <br /> Received by Date' Receipt No, Permit No. Issuance Date Mailed Delivered <br /> - - APPLICANT—RETURN ALL COPIES TO: ENVIRON]AEN�AL HEALTH PERMITISERVICESr 1601 E.HAZELTON AVE.,P.O.-Box 2009' STOCKTON,CA 95201 '�, <br />