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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR usE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) d / /7,411YVATER QUALITY <br /> Application is hereby made to the San Joaquin Local HeaPfhbi§trict fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wit San Joaquin County Ordinance No. d the roes and regulations of the San Joaquin Loc 1 Health District. <br /> Exact Site Address es n 2/y, �� /�' � �I, City/Town /�Ot lC_d6e <br /> Owner's Name a Phone �r ! 9-? <br /> Address City— <br /> Contractor's <br /> ity Contractor's Name a License# c`! Business Phone <br /> Contractor's Address,</21 ? ,,�0&z Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ X _ No <br /> TYPE OF WORK (CHECK): NEW WELL R DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ o? <br /> REPLACEMENT❑ f _ <br /> DISTANCE TO NEAREST: Septic Tank 50 + Sewer Lines Pit Privy <br /> Sewage Disposal Feld 1 bre t Cesspool/Seepage Pit Other <br /> Property Line d Private Domestic Well 't 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 4 <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal SQ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout CCS�k <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ,if 1422 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ 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 <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:"1 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 /> will Cjol for a G out spa prior to grouting and a final inspection. <br /> Signed X Title: LdZAf AA!- Date: <br /> (Draw Plot Plan on Reverse ici ) <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> PHASE I n <br /> Application Accepted By WA� Date <br /> Additional Comments: <br /> P�se 11 Grout Inspection Phase III Final Inspe <br /> Inspection By. Date /"Z' 6/ Inspection By _ Date <br /> OF- <br /> Fee IS Due: ❑ ANNUALLY 0000 00 <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receiv y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 19 <br /> Received by Date Receipt No. Permit No. Issu *e D to li Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />