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Applications 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 /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) �+�Saa E. Ef16-1-EWy} WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Dis r tfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. F <br /> Exact Site Address If <br /> R v Sf3 `� City/Town <br /> Owner's Name A 'gip- be"I- / Phone <br /> Address ' �`.,. s ` 4, City .. : <br /> Contractors Name ��-f r•..r i -��' License# #Z_f' Business Phone_ <br /> Contractor's Address �J f Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION d PUMP REPAIR 1 <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 <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grout ,j1� <br /> © DISPOSAL ❑ OTHER Other Information !Q <br /> ❑ GEOPHYSICAL Surface Seal Installed By.. <br /> PUMP INSTALLATION: Contractor :�7z r ^' y- <br /> rn <br /> Type of Pump msµ`" f +i s'!r r# f H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> / 'i <br /> PUMP REPAIR: 0 State Work Dane- <br /> r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure a Z <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, state laws, and rules and regulations of the San Joaquin Local Health District. =r <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 work man's.compen sat ion laws of California." <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 all for a Grout Inspection prior 10 grouting and a final inspection. <br /> ,� . . <br /> Signed X —,°�°,;,fit'f �-,.�:::� :!-a ' s,�.�� Title: ��'f � __ Date: <br /> / {t (Draw Plot Plan on Reverse Side) <br /> FDR EPARTMENT USE ONLY <br /> PHASE f i <br /> Application Accepted By `'= /.,_� - .ZI -- Date j <br /> Additional Comments: <br /> Phase it Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Dile: ❑ 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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> / AMOUNT <br /> FEE lh 1!✓ n f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dath Receipt No Permit No. Is uanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />