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Applica ttons,Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />:. FOR OFFICE USE APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> r. PUMP&WELL y <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wl h San Joaquin County Ordine No 1862 and the rules and regulations of the Sanj�aqufn Local Health District- <br /> Exact Site Address. a}�c&A;E Els�"i. City/Town jxznj Aos. Q�2-,_ <br /> Owner's Nam l Phone if 1P <br /> Address ) mE LS In ap L77, City <br /> Contractor's Name License#216 0& Business Phone 2 '-Y j <br /> Contractor's Address C/L w-. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �7 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ # <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <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 /> ❑ INDUSTRIAL ❑ 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 W <br /> ❑ CATHODIC PROTECTION 1ROTARY Type of Grout Q <br /> ❑ DISPOSAL 0-OTHER Other Information <br /> ❑ GEOPHYSICAL //�� 1 (� S.��u....rfa��c��e�Seal Installed By: <br /> A4 <br /> PUMP INSTALLATION: Contractor 41 e' I \� ; <br /> Type of Pump H.P. I <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: �State Work Done <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 <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 /> ;t. <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 C^-I for Gro n pection prior to grouting and a final inspec ' ! <br /> � _ E I <br /> Signed X � � :. Title: y --+-�-L� Date: //oC& I <br /> {Draw Plot,Plan.oh Reverse,Side)=_: <br /> • - r <br /> F DEP TMENT USE ONLY <br /> PHASE <br /> Application Accepted By �`'"�-" Date <br /> Additional Comments: <br /> Phase II Grout Inspection e 1 Final Inspection <br /> Inspection By Date Inspection y Date _- <br /> Fee Is Due: El ANNUALLY [I PER UNIT C1 PER SITE C1 EACH 11 January 1 Received By January 31. ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REM}TTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> /� � 8�f r � S 8 L-(•�5 3 �S ��S � - <br /> Received by Date— _ Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES­>;- - 1601 E.HAZELTON AVE,,P.O.Box 2009` STOCKTON,CA 95201 , <br />