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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICEvUSE: APPLICATION , <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) uWATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora perm_it to construct and/or install the work herein described.This application is <br /> made in compliance an Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin,Local Health District. <br /> Exact Site Address i �1/Lf�E' �h J City/Towne k afJh1'�" <br /> j Owner's Name � �� /,_)/,, /A}:r�Z3' Phone- La F <br /> Address City, f <br /> iContractor's Name CAY'v- 4y License# Business Phone + <br /> Contractor's Address Ca f "Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL. ^ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ A <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT _ <br /> DISTANCE TO NEAREST: Septic Tank �J� 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 / rj <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> / rt <br /> DOMESTIC/PRIVATE l ❑ GRILLED Dia. of Well Casing <br /> t ❑ DOMESTiC/PUBLIC ❑ DRIVEN Gauge of Casing / 6 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL © OTHER Other Information 67,, <br /> ❑ GEOPHYSICAL Surface Seal Installed By: - - <br /> PUMP INSTALLATION: Contractor r <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 <br /> Describe Material and Procedure e <br /> E I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ` <br /> i; ordinances, state laws-and rules and regulations of the San Joaquin Local Health District. y <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit a <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 will call for a GroIMirltin and a final inspection. <br /> Signed X' utTitle: r Date: <br /> i (Draw Plot Plan On Reverse Side) <br /> 1 ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date 7 �� <br /> Additional Comments: <br /> Plias II Grout Inspection / e III Fina nspection ' <br /> Inspection By-fir///� Date S_`r_S Z Inspection Bytom+ Date <br /> I 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 /> BILLING REMITTANCE $ <br /> 'BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED ' <br /> AMOUNT <br /> FEE ��.( ). �i J <br /> t LESS x <br /> PRORATION I <br /> PLUS - <br /> PENALTY <br /> OTHER - - <br /> i V OTHER i A Itf <br /> a. r _ <br /> t - <br /> Received by Date - Receipt No.�.-- Permit NO.. - Issuance Date Mailed - Delivered <br /> APPLICANT—RETURN AL, j,' MES TO: ENVIRONMENTAL HEALTH PERMtTISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201- <br />