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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR E USE: ` APPLICATION <br /> 1✓ (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 1011 J Ly k.X <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is v <br /> made in compliance with San Joaquin County Ordinance o. 1862 and t rules regulations of the San Joaquin Local ealth District. , <br /> Exact Site Address 1446 n— �� City/Town -?-,r7 �~G' <br /> a � <br /> Owner's Name Phone 3 <br /> AddrVss City '' <br /> Contractor's Name License# /_2J__1. Business Phone d `1 3 - 7l3 A I 1 <br /> Contractor's Address, to i. ��1' Ar-�- Yrn-ergency Phone <br /> Is Certificate of Workman's Compensation Iflsurance on File With'S L D? Yes 1p' 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 - 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 B'DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing_ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 2-VOTARY Type of Grout <br /> 11 DISPOSAL ❑ OTHER Other Information _ <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 /> 1 s Describe Material and Procedure v' <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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." ` <br /> I will call for a Grout Inspection prior to grouting and a final inspection. y <br /> Signed X f� !te, Title: Date: C <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTM NT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Addi9onal Comments: <br /> Ph e Grout 1 pection 'f Phase 111 Final Inspection <br /> Inspection By Grout ion <br /> �'� ` Inspection By Date \Z 3 <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 /> `7 <br /> Received by Date Receipt No. Permit No. Iss ance Mate Mailed Deliver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />