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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> +6`FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> t� PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to constructand/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 H alth District. i <br /> Exact Site Address �p �/'�_�- City/Town �I ��C. CID <br /> Owner's Name �- a l'1 Phone �is "" © 7 -�5 <br /> r City <br /> S •r C�--- <br /> Address rI y <br /> Contractor's Name �� [ -� - r _ � License# 3 �i_ir� Bu��ssi1iness Phone z <br /> Contractor's Address ��3� ��. � Emergency Phone 7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER.5. PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ ' <br /> I <br /> DISTANCE TO NEAREST: Septic Tank ! Sewer Lines Pit Privy <br /> Sewage Disposal Fi�tll Cesspool/Seepage Pit Other <br /> Property Line�f Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL _ + <br /> ❑ INDUSTRIAL # ❑ CABLE TOOL" Dia. of Well Excavation-- <br /> 1K DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well.Casing_ <br /> ❑ DOMESTIC/PUBLIC v ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface-Seal Installed By: <br />' PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: '.r..y ' , ❑ State Work Done - <br /> I � <br /> I DESTRUCTION F�ECL: :;a,// �� �Well Diameter - Approximate Depth <br /> �40 bescribe Materi nd Procedure - iliP60 '.2 ND <br /> I hereby certify that I gave prepared this application and that the work will be done in accordange-with San Joaquin County <br /> ordinances, state laws,�nd rules and regulations of the San Joaquin Local Health District. <br /> Horne owner or license agent's signature certifies the following:"I certify that in the performance of th11 e 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 for which this <br /> permit is issued,.1 shall employ persons subject to workman's compensation laws of California."1" <br /> 13KIII call for a Grout Inspection prios to ybuting and a final inspection. <br /> Signed X Title: �l_J �('t "' Date: —Cw— �® <br /> E (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONL <br /> PHASEI <br /> Application Accepted By ` Dat <br /> Additional Comments:- <br /> I Ph se I Gro nspeVti Phase III inal Inspection <br /> F Inspection By , Inspection By Date <br /> _r- <br /> i s <br /> ❑ P R SITE ❑ EACH 11 January 1 &Received By January 31 El July 1 &Received By July 31 <br /> Fee is Due., 11 A�N LLY [I PER 1111 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> t <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I / <br /> f OTHER <br /> OTHER- <br /> /—SEP <br /> � SI � <br /> o — <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> s APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />