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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OWE 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 permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County�Qrdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �d57G;J p�— ZA/xio 1 SLrX.4A 194 A4,r_J A,?Ci' — City/Town �/y�'€A37" OF A&,5r1 tf <br /> Owner's Name TP� AO!ty:5_ Phone ,20 <br /> Address City ."M CL1t �CC <br /> Contractor's Name Li ense# Business Phone <br /> Contractor's Address 54 4WaAA2A_, W06& Emergency Phone 5V.5--O7/ 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No C/J <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 /►DP1PF✓ Sewer Lines — Pit Privy <br /> Sewage Disposal Field 11AACesspool/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 /> 11DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing A;10 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing X41 <br /> 39 IRRIGATION GRAVEL PACK Depth of Grout Seal hi'm . <br /> ❑ CATHODIC PROTECTION f1co�rr ROTARY D Type of Grout 40-ne. <br /> ❑ DISPOSAL Jul OTHER Other Information Q — e <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 a <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 (n <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I�will pall for a Grout I specti prior to grouting and a final inspection. 1 �� <br /> Signed X /` - tC Title: ` _4� __ b L�� Date: 5 oZ O <br /> (Draw P t Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE � i p <br /> Application Accepted By ©� Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phise III Final Inspection <br /> Inspection By Date Inspection By Date 144 <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEES <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by I Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E..HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />