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I Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. j <br /> FOR OFFICE USE: ✓ �. APPLICATION <br /> W' (For Non-Traniferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY,.,, R. A <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/orinstall the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 6 and the rules and regulations of the San Joaq in Local Health Dist 'rtr� <br /> Exact Site Address <br /> ,� 1 �f 7'� City/Town �'! �`-'r" <br /> Owner's-Name A2 Phone 01 <br /> Address City <br /> Contractor's Name. License# 72=Z,2:V,), Business Phone ce <br /> Contractor's Address7 , Emergency Phone 6 <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): _m NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank 0a Sewer Lines UPit Privy "'"' <br /> . Q' <br /> Sewage Disposal Fie-)d fft2 61 '7" 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 Ilk i r <br /> ❑ DOMESTIC/PUBLIC ❑.DRIVEN Gauge of Casing f019 <br /> 3 <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 57e../_ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL tV--) ❑ OTHER Other Information <br /> El GEOPHYSICAL t Surface Seal Installed By: +��y..+ �ot!r: <br />' PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done �1 <br /> PUMP REPAIR: ❑ State Work Done fn <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth rQ <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 /> 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 ca I fora Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: a01" Date: <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY „ p <br /> PHASE I t y - k <br /> Application Accepted By Date <br />' Additional Comments: <br /> P a Grout I pectionZ Ilf R l Inspection <br /> Inspection By ate �` inspection By h a Date r <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 /> BILLINGREMITTANCE <br /> BASE EXPLANATION DATE DATE { REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION r _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ° f <br /> lyr 7-7/0-- <br /> Received by Date Receipt-NO. Permit No. - Issuance Date Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />