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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transierable, 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 `` l�30 /(j / S �� City/Town LQn/ def? i <br /> Owner's Name 4��K r% I1/rp�0 Phone qr ed gq � r <br /> Address .140 30 City <br /> Contractor's Name se#'_3 0*' Business Phone 7 1 <br /> Contractor's Address VD AW;( /4L,aMEAe n` k r� ffmergency Phone -7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo ..� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTIO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 OTHER ❑ PUMP INSTALLATIOIf PUMP REPAIR❑ <br /> REPLACEMENT❑ �y <br /> DISTANCE TO NEAREST: Septic Tank Sewer LirSef;ZCPit Privp <br />! Sewage Disposal Field Cesspool/Seepage Pit T Other <br /> _Property Line. Private Domestic.Well, Public..Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 13DOMESTIC/PRIVATE 11_DRILLED r.— Dia. of Well Casing _ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information + <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump SUTAIgFSIRLAq- H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> v <br /> f 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 /> Home owner 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 employ any person in such manner as to become subject to workman's compensation laws of California." G <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 /> j I will call for a Gr ut Inspection prior to grouting and a final inspection. <br /> ! Signed X — Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPA TMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection y_Ph a III Final Inspection <br /> Inspection By Date Inspection By <br /> +I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July f &Received By July 31 <br /> ._ REMIT <br /> BILLING � REMITTANCE �S•�- '. _ AMOUNT.AUE _ CHECKED <br /> BASE .._EXPLANAT ON . <br /> DATE. - . DATE REMITTEb 'AMIOUNT <br /> FEE ,A t L4,S ' <br /> LESS ,( <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 3 <br /> Received by - Date Receipt No. Permit No. Issubnce Date Mailed Delivere l <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />