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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> AOR G!FICE USE: APPLICATION <br /> IM (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with Sa Joaq in Cou ty Ordinance No. 186 and the rules and regulatiio, of t San J aquin Local Health District. <br /> Exact Site Address�{�,E97 'r Lim /ed %JA41; �/�. /V�. `City/T�v���� �i�wt/0 <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name Q License#�5��{/� Business Phoney <br /> Contractor's Address r<0_-4?_ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes , No <br /> TYPE OF WORK (CHECK): NEW WELL 9 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ / / <br /> DISTANCE TO NEAREST: Septic Tank Se wer Lines r�(� - Pit Privy <br /> Sewage Disposal Field/ Q(j 4 Cesspool/Seepage Pit - Other <br /> Property Line /)L Private Domestic Well- Public Domestic Well <br /> INTENDED USE TYPE OF WELL f <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ,�� r� <br /> ElDOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �i 1i414)£ <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: LA-)Al"- 1z <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 signat re certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons su ect to workman's compensation laws of California." <br /> I call oBa�ou nspe n pri o routing and a final inspection. ` o <br /> Signed X Title: ? Date: �C �t✓ <br /> (Draw Plot Plan on Reverse 8i0q) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n"r" <br /> ` _ p <br /> Application Accepted By— �`�' Date 1b-(� 6 <br /> Additional Comments: <br /> Phase II Grout Inspection P III Fin <br /> Inspection By Date Inspection By <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Janry s Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTA E $ <br /> `BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS y/ <br /> PENALTY V,/ <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu n, Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />