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4 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />. FQg OFFICfi USE: APPLICATION Q <br /> (For Non-Tran6ralile, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN.TRIPLICATE) WATER QUALITY <br /> Applicationisherebymad etotheSan JoaquinLocaIHeaIthDistrictf0rape rmittoconstucta d/o ri stalIthe workhereindescribed.Thisappl1cationis <br /> made in compliance wA uin Cimnty Or n nce o. 1862 and the rules and regulations of the San Jo a uin Local Health District <br /> Exact Site Address_ � J r City/Town <br /> v <br /> Owner's Name O�-A. '�r � Phone � <br /> Address ; f '�' _- CityTb w <br /> Contractor's Name C(— C IAXIT I License#i.3&Q 0 Business Phone 6Z f <br /> Contractor's Address Z Z. A' w " "Emergency Phone F " r.: d <br /> Is Certificate of Workman's Compensation Insur ce on File ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): 'NEW WELLDEEPEN ❑ RECONDITION❑� DESTRUCTION❑ -" <br /> WELL CHLORINATION ❑- WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP.REPAIR❑ <br /> REPLACEMENT❑. !� 0��1�.( a�l � <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 92 <br /> YPE OF WELL /( s <br /> 13 INDUSTRIAL 92 CABLE TOOL Dia. of Well Excavation 1� <br />` ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> t ,❑�, DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 2 <br /> I�+IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Af <br /> i ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> I ❑ DISPOSAL ❑ OTHER Other Information Ali <br /> 1:1 Surface Seal Installed By:' <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump F H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I Describe-Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Courtly <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 /> a , <br /> I w r a Grout Inspection:P46 to uung and a final inspection. <br /> A <br /> F <br /> Signed XI, Title: Date: <br /> (Draw Plot Plan on Reverse Side) ,(h <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> Application Accepted By -- - - Date/ <br /> Additional Comments: <br /> Phase II Grout Inspection Ph e I Final Inspection <br /> - Inspection By- Date Inspection By/�J+ � pale ..- � <br /> Fee Is Due:-❑''ANNUALLY `❑PER UNIT ❑ PER SITE ❑ EACH ❑ January,1 &Received'By January 31 r ❑ July 1 &'Received By July 31 - <br /> f REMIT <br /> .BILLING.- REMITTANCE $ <br /> BASE- EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS 2 �. <br /> PRORATION <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> i <br /> rt OTHER <br /> Received!7y Dale - - �- Receipt No.' - � -- - . Permit No. fssuariica 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 />