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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR 0' SCE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP u 1%,ELL <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 witLS Jo n County Or inan e No. 1862 and the rules and regulations of the San J aquin Local Health District. <br /> Exact Site Address . int�r1 City/Town 4C�'k u s 2a 7 <br /> Owner's Name � /IR I!� /acs t' — Phone <br /> Address N4 � _ City <br /> Contractor's Name License#, 3 1/� Business Phone �F_ .3_ �Q <br /> Contractor's Address�C1L __.. Emergency Phone _ I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLa DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank _<0 $ewer Lines r f, _.. Pit Privy ----- - <br /> Sewage Disposal Field d ( Cesspool/Seepage Pit Other <br /> Property Line 104 Private Domestic Well y k Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Weil Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing _ <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casinge�.. �/3 V <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal SO <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout e-4 <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 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 forwhich this <br /> permit is issued, I shall employ pe sons subject to workman's compensation laws of California." <br /> I wi I for ro Insp do rior to grouting and a final inspection. <br /> Signed X Title: 11 Date: <br /> (Draw Plot Plan on Reverse e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> AM <br /> ut Inspection �� axe III Final Inspection <br /> Inspection By Date�L� � Inspection B 'I–, Date � <br /> P Y 1 `-- <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> T REMIT <br /> BASE EXPLANATIONBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE ,' TTED AMOUNT <br /> FEE <br /> y - <br /> t� - L l <br /> LESS <br /> PRORATION <br /> PLUS - f - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. ssua a Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />