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_,, 54pplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> MSE: APPLICATION <br /> r (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> UV <br /> 'ETE IN TRIPLICATE) WATER QUALITY <br /> on 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 /> corrrpliance with San Joa uin County S rdmance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exa t c Address `7 6- City/Town fS-T700_V_ i Q-44 - <br /> l. 1✓ Bry t lz-s Phone 44 (o - _,5Ow -A�c y <br /> n;.,; game <br /> Address �1 4 (2 A City <br /> _Con`tract's Name m AA 0 A I)D License#lqj�ZQ_D_ Business Phone��p <br /> k Contractor's Address h' T 10-A qc/ Emergency Phone T r?14 <br /> „.Is Certificate of Workman's Compensation Insurance on File With SJLHD?. Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION IJ DESTRUCTION❑ _ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAI <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST: Septic Tank r Sewer-Lines Pit Privy <br /> Sewage Disposal-Field Cesspool/Seepage Pit 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 /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> f <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracted <br /> EE Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done I <br /> k PUMP REPAIR: '❑ State Work Done <br /> DESTRUCTION OF WELL: _ Well Diameter Approximate Depth <br /> I, Describe Material and Procedures <br /> r. <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 for which this permit <br /> f is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> I' 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 rsons ubject to workman's compensation laws of California." <br /> c I far a Groutins n prio o grou ' and a final inspection. <br /> � [e_� G -7 <br /> Signed X Title: ����, Date: �a <br /> (Draw Plot Plan on Reverse Side) <br /> FOR PARTMENT USE ONLY <br /> PHASE I _ i 2 ,� 7 <br /> Application Accepted By _ Date <br /> Additional Comments: <br /> Phase II Grout Inspection ha lJ inal Inspection <br /> { Inspection By Date Inspection By/ !r_,00A Date < <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July i &Receivedly 31' <br /> BILLING REMITTANCE $ REMIT _ <br /> BASE EXPLANATION D TE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE .^ <br /> LESS <br /> PRORATION ] } <br /> PLUS <br /> PENALTYr'Zv <br /> r <br /> OTHER f �� ��I ���f � 5 ��rO� t�►o�i� h^ �Sih`�. <br /> i OTHER''? <br /> .A <br /> Received by Date Receipt No._- '��� .:Permit No,'^ --.(ssuance Date ?—_Mailed Deliver6d _- P� <br /> APPLICANT—RETURN ALL COPIES TO: –ENVIRONMENTAL HEALTH PERMIT/SERVICES- 'x ?01 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201�'� <br /> � __ <br />