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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> ' <br /> FOR---OFFICE.USE: APPLICATION � <br /> (For Non-Transferable, Revocable, Suspendable) _S:1 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan 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 County Ordinance No. 1862 and the rules and regulations of the San Joaquin LQc�ll Health District. <br /> y <br /> Exact Site Address 2� �V If _t'A L City/Town � � <br /> Owner'S Name U�� 9 FX IA Pn s Phone <br /> Address � City <br /> Contractor's Name r License#� Business Phone j. <br /> Contractor's Address .2 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance onile With SJLHD? Yes No <br /> i TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> t WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank o Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL k <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> v If,"- Sr'►.t <br /> I DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> r <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout G�'rIt <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> f' Type of Pump H.P_ <br /> f <br /> l PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done G <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> C <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 /> Home owner or licensedagent'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." (V <br /> Contractor's 'ring or sub-contr ietin signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is i ed, I shall employ pe ns subject to workman's compensation laws of California." <br /> I will or a Grout spec to rior to grouting and a final inspec ' n. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Re rse Sid <br /> 4 <br /> FOR PEPAR MENT U ONLY <br /> PHASE [ <br /> Application Accepted By <br /> Date 7 <br /> Additional Comments: , <br /> Ph7s I Gro Inspection P ase III F nal Inspection I� _ <br /> Inspection By Date Inspection By Date <br /> ' Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REM#T <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ( DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> i PRORATION <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 'zn>k--a-4,b <br /> 0�]4 <br /> Received by Date - Receipt No. Permit No. Issuance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />