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ApplicationsWill Be ProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. ; <br /> FOR-0FF;CF_USE:;a APPLICATION <br /> (For futon-Transferable, Revocable,Suspendab� <br /> - <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �: I <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San oaquin County Ordinance No. 1862 and die rules and regulations of the San Joaquin Local Health District, 3 <br /> Exact Site Address I 1 f City/Town <br /> Owner's Name - 744elfeN � .,4 A"" -e--Phone a <br /> Address r Z1 l / / <br /> City . _.. <br /> Contractor's Name �. l ' License#3 !k7,Z% _ Business Phone <br /> Contractor's AddressZ/.lzr/ Emergency Phone O <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_K No <br /> TYPE OF WORK (CHECK): .',NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ .OTHER ❑ PUMP INSTALLATIONJ; PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank � r� , Sewer Lines Pit Privy <br /> Sewage Disposal Field � � Cesspool/Seepage Pit r Other <br /> :Property Line /,� Private Domestic Well//l6 Public Domestic Well <br /> INTENDED USE Ci'tauc( Std) TYPE OF WELL <br /> © INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation o1 f <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing trr✓ <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casings <br /> ❑ IRRIGATION it <br /> J2 GRAVEL PACK Depth of Grout Seal Y91_ 71111 <br /> ❑ CATHODIC PROTECTION ,9 ROTARY Type of Grout _ rl,1�11i1_ _ IfyO <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor / <br /> Type of Pump H.P. 11 <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 persons subject to workman's compensation laws of California." <br /> I will Call for aaa Grout <br /> Inspect!oa-prior to grouting and a final inspection. <br /> Signed X an �G�� ��,.�y -. Title: Date: —X,__'44_11 :1ra <br /> (Draw Plot Plan on Reverse Side) <br /> `• FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection. _, _ Phase III Final Inspectio �n <br /> Inspection B Date Inspection By C cS1 Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑..January 1 &Rece_ived By January 31 ❑:Juiy 1 &Received By July 31REMIT ' <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED A <br /> DATE DATE REMITTED AMOUNT <br /> FEE � � "`� -.61.01 . <br /> LESS :- <br /> PRORATION ;!! <br /> PLUS <br /> PENALTY3� <br /> s. ^ � F <br /> OTHER <br /> OTHER <br /> AA_ 5k <br /> Received by Date Receipt No. .Permit No. -Isduancb Date Mailed Delivered <br /> ,APPLICANT—RETURN ALL COPIES TO:— ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952D7 <br />