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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR'OFFICE 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 madetothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is.,,,. <br /> Y <br /> made in compliance with San Joaquin Coun y Ordinance No. 1862 and the rules nd egulatlQns of the San Joaquin Local He Ith District. <br /> Exact Site Address GSL — I.ST al.21 '7( ty%Town ase,�,t � <br /> Owner's Name Al� Phone — g <br /> Address o?D�p 7Ci {u City eQ 7 <br /> Contractor's Name License# s�?qe YIO Business Phho�n <br /> Contractor's Address 40 Emergency Phones-Z�a <br /> Is Certificate of Workman's Compensation I,,/ <br /> n.surance on File With SJLHD? Yes X No J <br /> L/ <br /> TYPE OF WORK (CHECK): NEW WELL � DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ -1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 'pn Z/A n <br /> Sewage Disposal Field/J��f Cesspool/Seepage Pit Other `C� /` <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> U <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> rn❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> UP DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION nnRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 13-40TARY Type of Grout E <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. C <br /> PUMP REPLACEMENT: ❑ State Work Done .1. <br /> PUMP REPAIR: ❑ State Work Done 7 <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all fora Grout Inspection prior to grouting and;alfln Iinspection. `Signed X �5. ' l • Q E Cf� . Date: 7� ..2 <br /> tl ti (Draw Plot Plan on Rever -Y,de) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By VLkA., Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <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 /> b S�,6" <br /> Received by 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 />