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_ m __ <br /> Applications Will Be Processed When Submitted Properly Completed. B e I Sign The Application. <br /> FOR OFFICE USE: APPLICATIONIMAR c1 <br /> 1� (For Non-Transferable, Revocable,Suspendable) 2 1 198 <br /> PUMP&WELL <br /> khv ENVIRONMENTAL HEALTH PERMIT SAN i �,,- <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY H E!—i !i-I fD! r CT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with an Joa in County Ordinance N_�oQ. 1862 and th,�}r-�es and regulations of the Sa oaquin Local Health District. <br /> Exact Site Address � a 0_3S "i0 y City/Town p y t�Cn T� <br /> Owner's Name q Q 7 A Z&VA D0 . '� Phone SL /—$14 / i <br /> Address 1 City�T LC� a -- <br /> Contractor's Name d cs�'✓ License#Q79OZO Business Phone 6&!?-*Vy7 <br /> Contractor's Address Emergency Phone 540!%ig <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 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 <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: C� <br /> PUMP INSTALLATION: Contractor <br /> v <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 00 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:"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 /> 1 will call_W a Grout In cIII onpWor to grouting and a final inspection <br /> Signed X Title: =+ Date:e?4 " <br /> ell (Draw Plot Plan on Re erse Side) <br /> FO EP RTME T USE ONLY <br /> PHASE I <br /> Application Accepted By — Date <br /> Additional Comments: <br /> Phase it Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 5 5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMJT/SERVICES1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />