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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-Tt+ stera„"le, Revocable, Suspendabie) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Sann JJoa/�i/n CAo�unty rdina a No 1 62 and the rules and regulations of the San Joa Lin Local Health District. <br /> Exact Site Address �7-�Z /!/ ��tL � City/Town .7 <br /> 222 Ali— <br /> Owner's <br /> 3 <br /> Owner's Name Phone <br /> Address - City <br /> Contractor's Name <br /> icon # Business Phone � - Cl <br /> } Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �- No <br /> TYPE OF WORK (CHECK): NEW WELL Z�-'DEEPEN ❑ RECONDITION❑ DESTRUCTIONE] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 29- PUMP REPAIR❑ V <br /> REPLACEMENT❑ / 6 <br /> DISTANCE TO NEAREST: Septic Tank 4�0 t'� <br /> Sewer Lines 0Pit Privy <br /> Sewage Disposal Field A'O Cesspool/See page Pit Other <br /> Property p y Line Private Domestic Well 75' Public Domestic Well � <br /> INTENDED USE1 TYPE OF WELL C <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑,, DD ESTIC/PUBLIC 13DRIVEN Gauge of Casing -�� JtSO <br /> I�IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal C <br /> ❑ CATHODIC PROTECTION 9- OTARY Type of Grout ` <br /> ❑ DISPOSAL ❑ OTHER Other Information dam' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: - , Contractor daq �_ <br /> Type of Pump _�.4 ' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 6W <br /> Describe Material and Procedure <br /> 4 <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 pE?;anit <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 /> f I wit call f r a Grout 1 ctiprior to grouting and a final inspectio . <br /> Signed X Title: Date: <br /> t. s <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTME T USE ONLY <br /> PHASE I <br /> p <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection ` <br /> Inspection By Date Inspection By ate-��,�7- ? <br /> Fee Is Due: ❑:ANNUALLY ❑ PER UNIT ❑ PER S7E ❑ EACH. ❑ January 1 8 Received By January 31 ❑ Juiy 1 8 Received By July 31 <br /> € BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE TE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> I LESS <br /> I PRORATION <br /> I PLUS <br /> PENALTY <br /> L OTHER <br /> OTHER <br /> Received by Dalle Receipt No. Permit No. 4 r Issuance Date Mailed Delivered <br /> eT _ f <br /> � APPLICANT—RETURN ALUCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Y1601 E.HAZE-TON AVE.,P.O.Box 2009 STOCKTON,CA-95201 - �- <br />