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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OF'JCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with Sajn�Joaq%in Coun Ordina ce No. 1862 and the rules and regulatigns of the San Joaquin Local ealth District. <br /> Exact Site Add res�srA My Al .,t 0--/,�^' +G► ,ry r"�/ 1�'�'�' � _`City/Town �C�'f`7t�'-T-v' <br /> Owner's Nam ko,Ll Phone ; �t ewe <br /> Address 5lIIZd ( d74 A,' title City i!%-.*v,041e. I e <br /> Contractor's Name A. /'T 67,0si 4me� License# 1;?4?f1fa f Business r-2-1 2ef <br /> Contractor's Address r { Emergency Phoney <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1/' 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 t1S 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 l' <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ° <br /> ❑_.DOMESTIC/PUBLIC ❑ DRIVEN Gauge-of Casing e- <br /> 11 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal art ` <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:- rd,a t' <br /> PUMP INSTALLATION: Contractor � ,� 1* <br /> Type of Pump rc b H.P. 1 <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout lnspectio rior to grouting and a final inspection. <br /> lop <br /> Signed X ._ Title: > Date: — 5— �— <br /> (Draw Plot Plan on Reverse Side) <br /> OR D ARTMEN USE ONLY <br /> PHASEI <br /> Application Accepted By f" - e f`` Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date <br /> rr Inspection By Date <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT uL PER SITE, ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> 'BILLINQ REMITTANCE _ $_ <br /> BASE EXPLANATION DATE ;� DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> y. <br /> Recgiyed-by,__. _ Date Recei.pt,No. ,. Permit No. Issuance Date Mailed _..Delivered__ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PIFAMIT/SERVICES _ 16016..HAZELTON;AVE.;P.O.Boz 2009 STOCKTON,CA 95201 <br />