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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 /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) Z*Z S 5 n 1 '`� 2ATER QUALITY 1 Q <br /> Application is hereby made totheBa j aqu"inLocalHealthDistrict foapermit toconstruct and/or install the work herein described.This application is <br /> made in compliance vyith San Joaquin County Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site AddressW ON /yi�y`4N /Ivy City/Tpwn 7`© <br /> r_ v <br /> Owner's Name S� <br /> Address City <br /> Contractor's Name L!/ N License#1339 off Business Phone O <br /> Contractor's Address .2Z157 /SIEmergency Phone <br /> Is Certificate of Workman's Compensation Ins ranee on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tanky/�1/ Sewer Lines Pit Privy ��' <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well L2L Public Domestic Well <br /> INTENDED USE T PE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 'Il <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION GRAVEL PACK Depth of Grout Seal D <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout 42, <br /> ❑ DISPOSAL OTHERcr_c Other Information <br /> ❑ GEOPHYSICALj <br /> Surface Seal Installed By: -Se%es I <br /> PUMP INSTALLATION. Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done "1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> -li.- - 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 per ons subject to workman's compensation taws of California." <br /> I will for a Grout In ti - for to grouting and a final inspection. <br /> 01 Signed )( �Zll Title: _��� �- Date: �.�� <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTMENT USE ONLY i <br /> PHASE <br /> Application Accepted By Date 31-10 <br /> Additional Comments: - <br /> Phase II Grout Inspection Phase NI Final Indftction c� <br /> Inspection By h VDat uired Inspection 13y+7* , -- Date s �Z <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT'b- ❑ PER SITE ❑ EACH ❑'January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> o O <br /> Received by Datet Receipt No Permit No. Issuance Date Mailed Delivered <br /> l' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601'E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />