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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WEL ' <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.Thisap licationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and therulesand regulations of the San Joaquin Local Health District. <br /> Exact Site Address d ,S�pj� A 4 it c� City/Town Z_ 4 <br /> Owner's Name _ C. -C�/Y� Phone <br /> Address ! ��� ! City �.4 z <br /> Contractor's Name License Business Phone y z 7_ r <br /> Contractor's Address ,ZLp Emergency Phone l <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes e_._—__ No <br /> TYPE OF WORK (CHECK): NEW WELL 8---'` DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION &— PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _1;V0,�C 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 Or <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation /.1 <br /> R=MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casi �� <br /> 11DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal' fes' <br /> ❑ CATHODIC PROTECTION NARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALurface Seal Installed y: ' <br /> PUMP INSTALLATION: Contractor C -0:,47 <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> We%�e Describe Material and Procedure t\I <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 will Rall for a Grout Inspection prior to gr o tin and a final inspection. <br /> Signed X +�'t //L��G Title: Date: l <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By DateC f �� <br /> Additional Comments: <br /> h II Gr�onut Inspection se inal Inspection f <br /> Inspection By C Date Inspection By 0 Date <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 $— <br /> d <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> !0 <br /> LR eived by to Receipt No. Pyr it o. 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 />