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` Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR'oFFj£ usE: APPLICATION � s - <br /> (For Non-Transferable,Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) -a SO f. /Il. ftt 6-F4+.✓ -'f, . 7�✓J , 2- <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> { made in compliance with San Joaquin Co my Ordinance No. 18q2 and the rules and regulations of the San Joaquin Local Health District. <br /> ` a. <br /> Exact Site Address y9.rAt5 `1Lr iA Ail oto� City/Town <br /> Owner's Name �f du���l1� f G0 Phone <br /> Address — dr�'1 � fas-tee City Lro�o&V& �. <br /> Contractor's Name License# Phone2•- <br /> Contractor's Address cA, Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on 4le With SJLHD? Yes )e No ) <br /> ` TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ '� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 191 <br /> REPLACEMENT❑ <br /> 9 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy G, <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 /> IRRIGATION . ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r Surface Seal_Ins alled By: <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump H.P. - <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: IN state Work Done ;A<A•,-.2 w& 4ot' <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 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 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 /> I III all for a Grout Inspec n for o•g ting and a final inspection. <br /> Signed itle �� Dat_ f <br /> (Draw Plot Ian on Reverse Side) <br /> OR 9EPART NT USE ONLY <br /> PHASE I j <br /> Application Accepted By G� Date u <br /> Additional Comments: <br /> Phase II Grout Inspection e I Final spection F <br /> Inspection By Date Inspection By ate <br /> k Fee Is Due: ❑ ANNUALLY ❑ PER UNIT R PER SITE ❑ EACH ❑'January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMiT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DYE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT . <br /> FEE <br /> LESS r <br /> PRORATION <br /> PLUS <br /> PENALTY t <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No. Permit issuance Date Mailed '— Delivered <br /> �, - -.APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES-` 1601 E:HAZELTON AVE.,P.O.Box 2009 'STOCKTON,CA 95201 <br />