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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR C FICE USE: APPLICATION <br /> I <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permitto construct and/or install thework 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 aZ D 34 W VAA-VJS IgD City/Town <br /> I Owner's Name /t!i¢Qf� �` M Ate/ Phone fSQ aZo�a (� <br /> Address 14030 N T?d_-VtS "irJ - City I <br /> Contractor's Name _Pili License# 37019Z- Business Phone_1��`�^-3 7 <br /> Contractor's Address1! Emergency Phone _ -759-3¢ST" s <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Q <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 771�; Pit Privy <br /> Sewage.Disposal Field Cesspool/Seepage Pit' Other, <br /> Property Line,;UIa Private Domestic Well /l�-. 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 /> r ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> t, <br /> ' ❑ DISPOSAL ❑ OTHER Other Information W <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �S�/� � ���✓ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done t <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 /> 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 following:"I certify that in the performance of the work for which this permit <br /> 1 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection prior to grouting and a final inspection. I <br /> Signed X &C _ Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> i <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: f ' <br /> Phase II Gr6uftiispection._�4 Ph a III Final Inspection <br /> Inspection By Date —?0, 4 In pectin By to <br /> Fee Is Due: ❑ ANNUALLY ' ❑.PER IT PER SITE ❑ EACH ❑ January 1 &Received By anuary 31 ❑ July 1 &Received By.July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ s AMOUNT'DUEX'' I CHECKED <br /> DATE DATE REMITTED AMOUNTI <br /> FEE <br /> I LESS i <br /> j PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Mci16 CF4 <br /> Received by - Date Receipt No Permit No - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D1 <br />