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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFIeE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) f <br /> PUMP&WELL <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 Joaqui County Ordinance No. 1862 and the rules and regulations of the SanJoaquinLocal Health District. <br /> Exact Site Address � a ft���. k( p City/Town <br /> .it T�Cpi� pp <br /> Owner's Name AlJoIl ac Phone o!1 <br /> Address City ��+Cc( , _ <br /> Contractor's Name License# ,3 2l Business Phone 9(4 2?-'s S el <br /> Contractor's Address-A <br /> 00 ' Cac Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank t CC1 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 0 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I )- <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal To' <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout ✓v. ...�'� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Cil , v JD <br /> Type of Pump aJ 6k H.P. 72- <br /> PUMP <br /> PUMP REPLACEMENT: ❑ State Work Done I n <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 /> i d, Ishall not employ an person in such manner as to become subject to workman's compensation laws of California." <br /> Contr ct0r's hiring -contrac Ing signature certifies the following:"I certify that in the performance of the work for which this <br /> VX <br /> t issue shall employ rsons subject to workman's compensation laws of California." <br /> cell for specti nor to gr uti and a final insp n./ <br /> Signs Title: l Date: <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT US NLY <br /> PHASE I n^ C� C�U'�. ' <br /> Application Accepted By e yds.• Date <br /> Additional Comments: <br /> Ph out Inspection 11 I Insp on <br /> Inspection By � �n a Inspection By 2.�� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <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 /> Received by Date Receipt No. Permit No. Iss ance D to Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />