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i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> -A. (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto 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. ' <br /> Exact Site Address '7�8 -t•-a�ir� City/Town ^�i-onr moi[ <br /> Owner's.Nam_e : 7711 lav Phone• +••" <br /> Address .r.. '+ City <br /> Contractor's Name License#dw Business Phone? - <br /> Contractor's Address Emergency.Phone <br /> Is Certificate of Workman's Compensation Insurance on File th SJLHD? Yes _ No Cf, <br /> TYPE OF WORK (CHECK):"'-'NEW WELL❑ ` DEEPEN ❑ -RECONDITION O -DESTRUCTION❑'- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP.INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ Il i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines a Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> F Property Line P ri vate'Domestic Well Public Domestic Well <br /> j INTENDED USE A TYPE OF WELL r <br /> t ❑ INDUSTRIAL a ❑ CABLE TOOL "` - Dia. of Well.Excavation <br /> I DOMESTIC/PRIVATE !, 11DRILLED _ s ;Dia. of Well Casing ' <br /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN] w Gauge of CasingIX <br /> 4 ❑ IRRIGATION . ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ,: Type of Grout <br /> ❑ DISPOSAL " 13OTHER Other Information, <br /> ji <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _. <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump ate- H.P. J <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: " Well Diameter - Approximate Depth <br /> f Describe Material and Procedure <br /> I 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 /> Home owner or licensed agent's signature certifies the loll owing:"I certify that in the performance of the work for which this permit <br /> g 9 <br /> is issued, I shall not employ any person in such rrianner.as to become subject to workman's,compensation laws of California." _s - <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 t ro tin nd inaLiins ct' _. .. <br /> Signed X � Date: <br /> (Draw Plot Plan on Reverse Side) <br /> is <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> f <br /> Application Accepted By;' <br /> g pate_" <br /> Additional Comments: <br /> Phase 11 Grout Inspection i Ph e I I Final Inspection Gam/ ILI <br /> p.� .,Inspection By I j Date Inspection 6y ate <br /> Fee Is-Due: 11 ANNUALLY 1 PER-UNIT - ❑ PER SITE ❑-EACH ❑ January 1 &-Received By January 31-.--- ❑ July 1 &Received By July 31 <br /> REMIT <br /> - - BILLING REMITTANCE $ -. AMOUNT DUE CHECKED <br /> BASE EXPLANATION .:.- <br /> 1 DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ih' r fi– , - <br /> PRORATION 1 <br /> PLUS <br /> PENALTY >> i - <br /> .y <br /> OTHER- <br /> OTHER - 9.' - <br /> t <br /> Received by Date r _Receipt-No. Permit No _(Issuanceloote Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITSERVICES 1601 E.HAYELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />