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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-Transferable,Revocable,'Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY i <br /> Application is herebymade to the San Joaquin Local Heaitti'DistnCtfo a pertnitto'constV-uctand/or4ns a"4�thework herein described.This application is <br /> made in compliance with San Joaquin.County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> `� 2 7,� / bity/ own C r-Q M @ etiok 0& <br /> Owner's Name 1-7r Phone " �6 <br /> �/ <br /> Address _S=-,6N Q City <br /> Contractor's Name 6c>rt,5S License#,/Z2-2 3 Business Phone <br /> 1 + <br /> Contractor's Address? y fi - f;z F&A, b -- Emergency Phone em "Z <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 0"'DEEPEN ❑ RECONDITION 0— 'DESTRUCTION❑ # <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ � I <br /> DISTANCE TO NEAREST: Septic Tank /t Sewer Lines �:e2s Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Weil <br /> INTENDED USE TYPE OF WELL <br /> R ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> Ig'6OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal =� <br /> ❑ CATHODIC PROTECTION E!'-MTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> z�❑ GEOPHYSICAL Surface Seal Installed y: <br /> PUMP INSTALLATION: Contract C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done i <br /> PUMP REPAIR: ❑ State Work Done n <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 i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I <br /> �► <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 following:"I certify that in the performance of the work forwhich this <br /> ,;.permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> "'I will call or a Groqt Inspection prior to grousing and a final inspection. <br /> Lt <br /> ' Sigriee'd X Title: Date:(. <br /> Aw (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> Application Accepted By Date <br /> Additional Comments: 4 <br /> h s II Grout Inspection a It Final t spection ? <br /> ti Inspection By Date,4 IF <br /> i Inspection ByfArty Date <br /> l 10 <br /> j _ . <br /> Feels Due: ❑- ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31€ ❑ July 1 &Received By July 31 <br /> r BILLING + r REMITTANCE <br /> BASE r EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED -3 <br /> AMOUNT <br /> FEE � r� <br /> b <br /> LESS <br /> PRORATION <br /> PLUS - f <br /> PENALTY ` <br /> OTHER <br /> OTHER <br /> Received by D to I Receipt No. Permit No, - I nuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 3 <br />