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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FORJOFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL /v <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 OCdinance No. 18 2 and the rules and regulations of the San Joaq In L al Health District. <br /> Exact Site Address '?S� 11�/4 fb�dMG _ City/Town _ <br /> Owner's Name 4440 V4,AA1A_ Phone _ <br /> - <br /> Address .74-a4— a Al A6#tJIVC -- City . <br /> Contractor's Name -'1''-aw0l9 t-' ' 2 License#-Z-f-?I-J"—Business Phonea cj" 7 Ir 7!,, <br /> Contractor's Address :Zd _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File 4th SJLHD? Yes__ ___ No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ t� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ <br /> REPLACEMENT❑ f <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 Ins__22) <br /> al 2d By: v <br /> PUMP INSTALLATION: Contractor �a.` C.� 2 " <br /> Type of Pump Sk H.P. l <br /> PUMP REPLACEMENT: ® State Work Done "'t r jeA*&A ,tr 't`-APa4c..1/ ,f fE�►aw An+� t"I�� 1 <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:"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 /> I wi call for a Grout Inspectio pr r outin and a final inspection. <br /> Signed X 'tie: Date: Gsr" f <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ^ n <br /> Application Accepted By 1✓041 Date <br /> Additional Comments: <br /> Phase II Grout Inspection iil <br /> l <br /> Fipdl Inspection �. <br /> Inspection By—,, Date Inspection By I/1`1G'�' Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE If <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <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 PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />