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Applications Will Be Processed When Submitted Properly Competed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I'd, APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL 1 <br /> 1 ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with SanJoaquinCounty Ordinance No. 1862 and the rubs ar rsy�tl pations of the San Joaquin Local Health District. <br /> Exact Site Address /�f� � 1 A4,16S sat'A v*p Vg ADAM '.f'1 A.rtkd.. City/Town <br /> Owner's Name / '� ►J �1 rPh �d _ Phone <br /> Address }? je .S u City <br /> Contractor's Name License# Business Phone s 1• <br /> Contractor's Address ®a 7e Emergency Phone _ _ _.-- <br /> Is Certificate of Workman's Compensation Insurance on File W' h SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ �l <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ Pit Privy i *'F11 <br /> ._ <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 ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> L� IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal .7 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor CS41C.,a __Z.. <br /> Type of Pump H.P. ?.r <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done rf aplpea 1 0, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> R <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 /> 1 ill call for a Grout Inspe n p 'or to ing and a final inspection. <br /> Signed 2J Date: l <br /> (Draw Plot an on Reverse Side) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By—/--' <br /> y- � �-.y!!! Dat <br /> Additional Comments: {— <br /> Phase!J.9fout Inspection Phase III Final Inspection <br /> Inspection ByDate Inspection By Date Q <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER C5 1-7 37 <br /> `79r~ic29 9/1&7y <br /> Received by Date Receipt No. Permit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,.,C.A 95201 <br />