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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY \L <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 J aquin County Ordinanc No. 1862Qand� the rules r ul�t Ions of the San qui L cal Health District. V <br /> Exact Site Address �� LQA �� �.ri . _ l�bfty/Town <br /> ,�76 i E. 4�1Q Co <br /> Owner's Name �-' Phone 'Y7 A <br /> Address -1 x;k '). � �2�__�``��5� City C <br /> Contractor's Name d U J License# Business Phone <br /> Contractor's Address es Emergency Phone 3(aq- 41 <br /> Is Certificate of Workman's CompensationI s r nce on File With JLHD? Yes I No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONAr PUMP REPAIR <br /> REPLACEMENT❑ l <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 fQ <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /a <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 'f <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ,W- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surfjpce Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. r1 <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 <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. 7v' <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 F <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will I for a Grout Insp tion prior grouting and a final ins Ion.. <br /> Signed X Title: Ya liZ14 Date: <br /> (Draw Plot Plan on Reverse Side) t <br /> FOR DEPART NT USE ONLY <br /> PHASE 1 q <br /> Application Accepted By Date 3� 7/ <br /> Additional Comments: <br /> Pas I Grout Inspection w s Final Inspectio �Q <br /> Inspection By Date �`• � � Inspection B Date ��1�` <br /> Fee Is Due: ❑ AN ALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 8 O v <br /> LESS O <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 8\-7b �79—g 8o 5?P/ /-7� <br /> Received by Dale Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTQN AVE.,>P.O.Boz 2009 STOCKTON,CA 95201 <br />