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F ApplicationsWill Be ProcessedWhenSubmitted ProperlyCompleted. Be SureToSign TheApplication <br /> ` <br /> OFFICE FF APPLICATION <br /> " USE: ;..-_-- -<.r. - <br /> (For Non-Transferable, Revocable,Suspendable) . <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) Lo,)V,1,6,e-,z96-r--WATER QUALITY 0( S-- 2-1 c--S <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des dbed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin pal He Ith District. <br /> Exact Site Address o City/Town _ !V jQ <br /> Owner's Name WOQ A)-P Phone <br /> Address 4 a X 7 An City J1ACkyVAJ <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No [ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDIT16N❑ DESTRUCTIONX <br /> WELL CHLORINATION ❑ WELL ABANDONMENT10 OTHER ❑ PUMP INSTALLATION ❑ 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 Well Public Domestic Well _ <br /> INTENDED USE TYPE OF WELL ` <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTiC/PRIVATE ❑ DRILLED Dia, of Well Casing J <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing W <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 C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter—hi Approximate Depth 'i ts <br /> Describe Material and Procedure) yrs Ca <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 /> " <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 /> I will a Grout Inspection prior to grouting and a final inspection. <br /> Signed X 4�"~-�' Title: � } �`?�� Date: f <br /> (Draw Plot Plan on Reverse Side) <br /> �L FOR DEPA ENT SE ONLY <br /> PHASE 1 <br /> Application Accepted By ��wvv Date �y U <br /> Additional Comments: <br /> Phase II Grout Inspectionse 1 f=inal Inspection <br /> Inspection By. M�A Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT E(PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE HATE REMITTED <br /> AMOUNT <br /> FEE —/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> (e 656q7 <br /> Received by Dat Receipt No. Permit No, Issuance Date Mailed ---Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95261 <br />