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4.0. g: <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. } <br /> .F r-u0"It3E USE: APPLICATION <br /> {+ bre- (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> r� ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 770 �t I�-�` City/Town p <br /> Owner's Name Phone <br /> Address 6 City , <br /> Contractor's Name P License#`Gc'a <br /> 73 Business Phohe 2� 1� -�, <br /> Contractor's Address f Emergency Phone f 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ c---- No , <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ t <br /> WELL CHLORINATI N ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L <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 t <br /> INTENDED USE TYPE OF WELL t' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED ! Dia. of Well Casing - _f <br /> OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> Ju IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal J -- <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHEROther Information <br /> ❑ .GEOPHYSICAL Surface S941 Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �Q.P;1 Q <br /> PUMP REPLACEMENT: tate Work Done , K <br /> i <br /> PUMP REPAIR: ❑ State Work Docnn <br /> e <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> � Describe.Material and.P.roceduro_ <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 /> 1 w' II f a Grout I sp on prior to grou 'ng and a final inspection. <br /> Signed X Title:. ­1 - Date: ^�Q <br /> (Draw Plot Plan on ReversAide) <br /> ,. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Gr t spectign Ph =gate <br /> ction // <br /> Inspection By Date Inspection By `/ 5 <br /> i <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El January 1 8.Received By January 31 ❑ July i &Received 8y July 31 <br /> REMIT <br /> B4LLING REMITTANCE $ f <br /> BASF EXPLANATION DATE DATE REMITTED -AMOUNT DUE CHECKED <br /> AMOUNT ! <br /> FEE <br /> LESS <br /> PRORATION t <br /> PENALTY <br /> OTHER <br /> OTHER E <br /> Received by Date Receipt No Permi No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />