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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOlk OFFICE USE: APPLICATION 4 <br /> (For Non-Transferable,'Rlwocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE 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. 86an the f ules and regulations of the San Jo quin Lo I Health District. <br /> Exact Site Address IY 91 Z, 11Q City/Town G <br /> Owner's Name l7T 4 e CPhone <br /> Address �} ,� N •�..�..o„ City G <br /> �7 <br /> 11 <br /> Contractor's Name L ss usinePhene !ra oC <br /> Contractor's Addres 00 40_%_�mergency Phone ,;j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4- No J <br /> TYPE OF WORK (CHECK): NEW WELL E�__DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 23''x' 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 / ye Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL sJ <br /> ❑ INDUSTRIAL 1:1 CABLE TOOL Dia. of Well Excavation Z1 <br /> 23"DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 7 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /a P <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 5-'ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL `,, � -► Surface Seal Installee By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump o H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r' <br /> Describe Material and Procedure <br /> 1 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 for which this <br /> permit is issued, i shall employ persons subject-to,workman's compensation laws of California." <br /> will c I for a Grout Inspection prior to grouting d final inspection. <br /> Signed X Title: ���jj+ �'`� Date: <br /> (Draw lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By�r rye A re C,_ Date <br /> Addi ' I Comments: <br /> 11 Grout Inspection i ha //1�/1���FFinal Inspection <br /> Inspection By Date 6 Inspection By i/�"+ 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 /> — <br /> FEE CLQ - <br /> FEE Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a i l 7-73f <br /> Received by Date Receipt No. `- 1?ermR No.` Issuance Date' Mailed Delivered <br />` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE'S YW1 E.HAZEL*6N AVE.,P.O.Box 2089 STOCKTON,CA 95201 <br />