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Applications Will Be Processed When Submitted Properly Completed. BeSure Iosign Inemppuc:auvTr. <br /> FOR OFFICE USE: APPLICATION II <br /> y L- (For Non-Transferable, Revocable, Suspendable) 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 constructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> f made in compliance with San Joaquin Courilty OrdlQnatJce No. 1862 and the rules and regulations of the 5an,4oaquin ocal Health District. <br /> Exact Site Address <br /> City/Town � � � <br /> '� <br /> tee, 6-A L07L) �r2gPhone F7 37 <br /> Owner's Name ell <br /> AddressCity_ <br /> Contractor's Name <br /> License#g N ? "Z Business Phone <br /> Contractor's Address i' Emergency Phone <br /> Is Certificate of Workman's Compensation 1n.srance on File With SJLHD? Yes. No <br /> TYPE OF WORK {CHECK): NEW WELL1 DEEPEN ❑ RECONDITION El DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 1:1OTHER ❑ PUMP INSTALLATION 12 PUMP REPAIR© <br /> k REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Lines Q Pit Privy <br /> _ Sewage Disposal Field is _ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 3 r� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> [3 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION ROTARY Type of Grout -P <br /> ❑ DISPOSAL ❑ OTHER Other Information ` <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL ts' <br /> PUMP INSTALLATION: Contractor -� <br /> Type of Pump H'P — r <br /> x, <br /> PUMP REPLACEMENT: ❑ State Work Done <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 /> 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." <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." <br /> 1 c Il for a Gro I pection prior to grouting and a sinal inspection. 7 fi <br /> Title: �j <br /> ([ / Date: <br /> Signed X l [ <br /> (Draw Plot Plan on Reverse Side) <br /> FORD PARTME USE ONLY <br /> PHASE 1 Q4 <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> I Grout Inspection Phase II�Final nspection <br /> Date - 16 � Inspection By <br /> Date <br /> inspection y ' <br /> k <br /> Fee is Due: ❑ ANNUALLY PER UNIT PK PER SITE ❑ EACH ❑'January t &Received By January 31 ❑ July 1 &Receiv REMITBy uIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> F FEE - <br /> LESS <br /> PRORATION - <br /> PLUS <br /> S PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No <br /> Permit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES Td: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON.AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />