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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ,,OR OFFICE USE: �J APPLICATION <br /> t� /Fv1O• (For Non-Transferable,Revocable,Suspendable) <br /> — ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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. 1862 and the rules and regulations of the San Jorma-g n Loyal Pealth District./ <br /> Exact Site Address /A) /�./l nih rc %�� City/Town CJCC�b CC 600%_ Gll <br /> Owner's Name 2daar +� /!� ��+ r e L7q� i Phone, <br /> Address -a'f /{� 'Y�fe _ f�^ City , ' �t- <br /> Contractor's Nam r License# 193—7 Z-S—Business Phone <br /> Contractor's Address 14 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on F�i/l With SJLHD? Yes �C No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEI<J ❑ RECONDITION❑ DESTRUCTION❑ J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® _9 <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 74e 3 <br /> Type of Pump H.P. Z� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: IN State Work Done�ce,W !A+>s+ rA, Otl'i/!es_1' <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." i <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I VVIII call for a Grout Ins p n for o gro ting and a final inspection. <br /> Signed �� ! Title: Date: <br /> or U (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 (�) <br /> Application Accepted By ) `-' Date ' ' <br /> Additional Comments: <br /> Phase 11 Grout Inspection P se Final Inspection '' <br /> Inspection By � Date Inspection By Date 2'7® <br /> fl <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 0 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 /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �9 <br /> Received by Date Receipt No. Permit No. Issua ce 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 />