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Applications Will BeProcessedWhen Submitted ProperlyCompleted. BeSureToSign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For hon-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin C unty Ordnance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /$ .I�ti ``A''C,, /�X ®.Ylr'rr' � �J�cA City/Town A-A;D,-.A� LO�iDta <br /> Owner's Name S z�G wt�� pf Phone * <br /> Address /8f® City <br /> Contractor's Name AM =- e5lo / s 151 License# Business Phone <br /> Contractor's Address -11� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—><. Nod <br /> TYPE OF WORK (CHECK): NEW WELL► DEEPEN ❑ RECONDITION 11DESTRUCTIONX <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑. PUMP REPAIR© n , <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> f> <br /> 11 INDUSTRIAL E] 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 MILROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> XGEOPHYSICAL Surface Seal Installed By: Ocatea it Ter <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �� Approximate Depth -SZ7 <br /> Describe Material and Procc&Lre <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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I c I for r ut I spect' prior to grouting and a final inspections. <br /> Signed X • °P Title: J' Slo-ter Er►rC.f' �� Date: ��"fig�a <br /> dcz (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY G� <br /> PHASE I <br /> � <br /> Application Accepted By. � ` Date <br /> Additional Comments: lir A <br /> Phase II Grout Inspectionh� a li Final nspection <br /> Inspection By DateInspection 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE (� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by 0ate Receipt No. Permit No IlIe ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />