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Applications Will Be Processed When submitted Properly Completed. Be Sure To Sign Th Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Translerable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT J <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY ��/��� s <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co my Or finance No. 1862 and thp rules and regulations of the San Joa uin.LOC�I Health District. <br /> Exact Site Address S O9 F.2 k C City/Town 2 z&–alffiY <br /> Owner's Name -ncc� l ) "e Phone f7-215X <br /> Address City <br /> Contractor's Name LL LCA License#,2 qfyAt— Business Phoney?d�– 7�/S`-a''�7eF <br /> 51Iy' 'rGt�dLfNP Emergency Contractor's Address � t Emer enc Phone ^' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_� No <br /> TYPE OF WORK (CHECK): NEW WELL O' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Q-- PUMP REPAIR 11 <br /> REPLACEMENT❑ <br /> r <br /> DISTANCE TO NEAREST: Septic Tank 71 Sewer Lines L©4 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 ❑ D�VEN Gauge of Casing Sc e <br /> ❑ IRRIGATION �GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION Q-ROTARY Type of Grout P <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: A,� az f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ct!s H.P. <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 /> 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 fallowing:"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 /> I will call 11 r a rout Inspection rior routing and a final inspection. <br /> Signed X Title: .tid• Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By r Date 0 <br /> Additional Comments: <br /> ha II Grout InspectionI spection�I <br /> Inspection By � Date a'�4 r1inspection By P Date 7C61 <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> g ` yE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> M �g" lei <br /> Received by I Date r Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Bo■2009 STOCKTON,CA 95201 <br /> it <br />