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n ~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 made to the San Joaquin Local Health District fora permit to construct and/or install the work he e described.This application is <br /> made in compliance with an oa�uin Cou .ty Ordi ance No. 1,862 and the rules and regulations of the Sarf�lo uin Local Health District. <br /> Exact Site Address �g "(- ' / (-' C. City/Tow <br /> Owner's NameV/,/- f + f � c' �J �°/� Phone <br /> Address City <br /> Contractor's Name - C C. _ ri-C, License -2--C"I Business Phone _ � /" <br /> Contractor's Address 6, ✓l4 , , ; - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes______ 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 /> 2-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information _ <br /> ❑ GEOPHYSICAL p"face Seal Instal d By: wl <br /> PUMP INSTALLATION: Contractor c� l_ <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 ell <br /> 1 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 /> Home owner 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 /> permif is issued, I shall employ per ons,subjecf"`to workman's compensation laws of California." <br /> I . call for a�Grg(it Jnsp/ection for o Ze <br /> ing and a final inspeAion. _ <br /> � i GC � Title• ! �-Z -.''. Date:Signed X . <br /> (Draw Plot Plan on Reverse Side) <br /> F ^� GOR DEPART ENT USE ONLY <br /> PHASE o <br /> Application Accepted By Date a <br /> Additional Comments: <br /> Phase II Grout Inspection Ph a III Final Inspection <br /> r� 1 <br /> Inspection By Date Inspection By o. rt-Daate ,h CJ <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT L PER SITE ❑ EACH ❑ January 1 &Received By January July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE all <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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 />