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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFISE USE: APPLICATION <br /> a y A (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLET IN TRIPLICATE) WATER QUALITY <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 San Joaquin {County Ordinance No. 1862 and the rules and regulations of the San J,oaq�In Local Health District. <br /> Exact Site Address `l:Z�-AMICK.1 pe, City/Town <br /> Owner's Name Tiot4R/A 44A"! Phone <br /> Address / City <br /> Contractor's Name ')� Wbl�►n 1�p /�. License# Business Phone _$9�'1 .1 <br /> Contractor's Address 7 T Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No T, <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPE ❑ RECONDITION❑ DESTRUCTIONS V•1 <br /> WELL CHLORINATION 11 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: <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 h. Approximate Dep;h <br /> Describe Material and Procedure ,5 <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 /> Home owner 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 wil ll for a Grout In ctpn prior to grouting and a final inspection-7 qo��l� <br /> Signed X Title:� � --XF9— Date: — �~ <br /> (Draw Plot Plan on Reverse Slde) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ —,> <br /> HASE I ` P _ <br /> Application Accepted By U Ale ' ( P� at v <br /> Additional Comments: a ✓d �� n <br /> Phase II Grout Inspection j Phase III Final Ins ection <br /> Inspection By Date } l', 1 Inspection By `�� Date <br /> M <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ 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 DATE REMITTED <br /> AMOUNT <br /> FEE �✓ � � � ' � r + �� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OT ER <br /> 7 d � 3 <br /> Received by I Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />