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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OF_:MCE USE: APPLICATION <br /> o` m y (For Non-Transferable, Revocable,Suspendable) <br /> t PUMP&WELL <br /> t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is,hereby madeto 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 County Ordinance Pp. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address f -` City/Town <br /> 5 so D C(y.4 ! <br /> Owner's Name / Phone <br /> Address Z zaj� City <br /> Contractor's Name _ License#f�,37.3 Business PhoneUJ <br /> ��-JnG. s I <br /> Contractor's Address ____._.- d , �7 Emergency Phoma <br /> Is Certificate of Workman's Compensation IWrance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ J <br /> WELL CHLORINATION ❑ ` WELL ABANDONMENT 11 OTHER E] PUMP INSTALLATION Z PUMP REPAIR❑ <br /> I <br /> REPLACEMENT❑ f i <br /> DISTANCE TO NEAREST: Septic Tank l Oi9 Sewer Lines_ n Pit Privy <br /> Sewage Disposal Field r DO + Cesspool/Seepage Pit Other <br /> Property LinePrivate Domestic Well Public Domestic Well <br /> I 4L. INTENDED.USE TYPE OF WELL I©„ <br /> ❑}P�DUSTRIAL ' = 11 CABLE TOOL Dia. of Well Excavation <br /> k DOMESTIC/PRI.VATE ❑ DRILLED TDia. ofWellCasing q <br /> ' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION (^ ❑RAVEL PACK Depth of Grout Seal 5� <br /> ❑ CATHODIC PROTECTION ffff [g ROTARY Type of Grout v <br /> 1:3 DISPOSAL f ❑ OTHER «� ` Other In#o" ion <br /> ❑ GEOPHYSICAL +� y!t i� Surface Seal II stalled By: <br /> T it 1 <br /> PUMP INSTALLATION: Contractor � "&�v -cd - . #. -ry <br /> Type of Pump oo r A' `�}�K.f- r t H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> `;l r� <br /> I PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL.: Well Diameter Approximate Depth <br /> y 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 /> 1 , <br /> 1 I will ca!I for a Grout Inspection prior to grouting and a final inspection. <br /> r ` <br /> Signed X !i/�/, � lq,�-r Title: 4 Date: �` •3`�/ <br /> Ii <br /> (Draw Plot Plan on Reverse Sid "" - <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 �n�+/1L/.. f - <br /> Application Accepted ByDate <br /> e--tea) — <br /> Additional Comments: <br /> P se II Grout l spection , ., Kase III F'. al Inspection --7 _ �� <br /> Inspection By Date 5��e� Inspectial Sy '� Date <br /> 14rs <br /> Fee Is Due: ❑ ANNUALLY 4 El PER UNIT ❑ PER SITE El EACH ❑ Janua"ry T"&'Receive'd By,January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> RASE - EXPLANATION BILLING DUE CHECKED <br /> DATE DATE REMITTED <br /> AMDUNT <br /> J <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER <br /> Received by by Date Receipt No. Permit No. Issua Ace D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601,E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />