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- <br />,� Applications Will-Be Processed-When Submitted Properly Completed. Bbure <br /> FOR OFEICE,USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> �... - <br /> ENVIRONMENTAL HEALTH PERMIT t <br /> (COMPLETE IN TRIPLICATE) ?Seo I W, c it �� <br /> WATER QUALITY_ ���r 1 q-0 r(7 <br /> Application is hereby madetothe n Joaquin Local Health District r per to construct and/or install the work herein desc ibed.This application is <br /> made in compliance w' Jo in County r ce,�V�. 2 d thct .r les and reg lYt�ipns of the San al Health District. <br /> Exact Site Address * � y Nt1I^ <br /> LJ A I�+ +City/Town r� <br /> { s i <br /> ' Owner's Name AM Phone u a } <br /> 1 Q V •'► City <br /> Address <br /> Contractor's Name 1r1�t�.4 License# Z Business Phone_ <br /> Contractor's Address m Emergency Phone - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 9"' DEEPEN ❑ RECONDITION.❑ DESTRUCTIO&'0" <br /> N�,❑/ i <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER E] PUMP INSTALLATION Idd'' PUMP REPAIR❑ <br /> REPLACEMENT❑ t ~ <br /> DISTANCE TO NEAREST: Septic Tank <br /> + Sewer Lines Pit Privy <br /> Sewage Disposal Field_���+�► Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well . <br /> INTENDED USE <br /> TYPE OF WELL <br /> •�� J �`l', <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> — <br /> 0 II <br /> ❑ DOMESTIC/PRIVATE Dia. of Well Casing � ash '�O ✓G <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Se <br /> D <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 1:1 DISPOSAL <br /> El OTHER Other Information �.. <br />! ❑ GEOPHYSICAL rface Seal Installed By: <br /> I <br /> PUMP INSTALLATION: Contractor f� �'� ~ <br /> Type of Pump S N.P. <br />+ PUMP REPLACEMENT: ❑ State Work Done <br /> ` PUMP REPAIR: ❑ State Work Done 0 <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter— <br /> Describe <br /> iameter ! <br /> Describe Material and Procedure <br /> i <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, skate laws, and rules and regulations of the San Joaquin Local Health District. l <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 hall not employ any person in ch manner as to become subject to workman's compensation laws of California." <br /> Contractor's h%i ng or sub-cont ting sig tur certifies the following:"I certify that in the performance of the work for which this <br /> permit is issue I shall emp S u t to workm pensation laws of California." <br /> I will cal G ut Inspe ng and inal inspection. <br /> Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> e II Grout I pection P II Final / <br /> FG <br /> O� <br /> �te��� �l � Inspection B <br /> Inspection By <br /> 61 d By <br /> l Fee IS Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janu r Received By January 31 El 1 &Receive <br /> REWTuly 34 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> l DATE DATE REMITTED AMOUNT <br /> FEE q <br /> LESS U <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> F OTHER <br /> i <br /> Received by <br /> Date Receipt No. Permit No. Issua ce Date Mailed Delivered <br /> k _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 200 STOCKTON,CA 9520 <br />