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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR O1 F_Lr_E-L1SE APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> {COMPLETE IN TRIPLICATE} WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County O-r-diinnance No. 1862 and the rul s and regulations of the San Joaquin'Local Health District. <br /> Exact Site Address *�G 1tr 4e AcwIl! � City/Town <br /> Owner's Name Ze 6II' ana Phone <br /> Address �Z":, <br /> City <br /> erase# /"72 Business Phone <br /> i Contractor's Name <br /> h, <br /> Contractor's Address Emergency Phone <br /> !; Is Certificate of Workman's Compensation Insurance on File h SJLHD? Yes � NO <br /> TYPE OF WORK (CHECK): NEW WELL_❑ DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION J9 PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field _ •Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Welll Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> {f ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑_,DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ 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 d <br /> Type of Pump G; H.P.. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP Fes: <br /> X State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 'Approximate Depth <br /> 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 m, <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." r <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 <br /> t III all for a'GrouI ec <br /> o prrt ro 'ng an a final inspection- <br /> I itle: Date: /Q <br /> Signed <br /> (Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I \2> �° <br /> Date <br /> Application Accepted By <br /> Additional Comments: �, p -- <br /> Phase it Grout Inspection �`�` ='�' ��s c�Phase!II Final inspection' <br /> Inspection By Date Inspection By Date <br /> 4 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMII BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE " CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> E <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. .Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 [�� <br />