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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 mad Joaquin Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance wit San oaquln County Or mance No. 1862Cd the rules and regulations of the San Joaquin ocal Health District. <br /> Exact Site Address A l��A kn � C City/Town 5�� /_Vo� <br /> Owner's Nana m C tz 0 a/d ` t ''-d v! oz L,- Phone <br /> Address &C- 3 / & CftivyCity <br /> Contractor's Name /U (cense# Business Phone 'f <br /> Contractor's Address Emergency Phone 40c G Q <br /> l!J <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO ❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Ir PUMP REPAIR <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank f Sewer Linesy Pit Privy <br /> Sewage Disposal Field �S�i Cesspool/Seepage Pit t_t, Other <br /> Property LineSlf) /--Private Domestic Well I Public Domestic Well .4'n''"-�' <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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ` <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Ah,i '4 X Vn.c. �✓ <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 <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 compensgtion laws of California." <br /> I I will call for a Grout inspection prior to grouting and a final inspe n. <br /> Signed X _�-�+�. Title: - Date: <br /> (Draw Plot Plan on Reverse Side) <br />� F DiEPRTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By r ^� '� Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection _.-Phas III Final Inspectio n <br /> Inspection By Date Inspection B Date 7 4L <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By J72"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 `j G <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 77 0 <br /> Received by Date Receipt No. Permit No. Issuance l3ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br /> a <br />