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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 /> ENVIRONMENTAL HEALTH PERMIT PUMP WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or installthework herein described.This application is <br /> made in compliance with San Joaquin Co�jl Ordinancy No. 18�6and the rules and regulations of the S n JoaquinL cal Health District. <br /> Exact Site Address_ Y I _ City/To 4;iiy��.4 . GqL-� <br /> Owner's Name I Phone <br /> Address _-_ o r�L. - city�/i���c,4Contractor's Name 3 <br /> _p # 24 Cly NI <br /> / Business Phone_ -�(2— 9 <br /> Contractor's Address Q mergency Phone <br /> Is Certificate of Workman's Compensation Insur e on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL Er DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION E�__PUMP REPAIR❑ <br /> REPLACEMENT❑ ` <br /> DISTANCE TO NEAREST: Septic Tank ~ --t— Sewer Lines Pit Privy _ <br /> Sewage Disp os31�2 Cesspool/�epage Pit Other_ <br /> Property Line_____ Private Domestic Well g1 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ,❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> �IJUMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing r� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑��GRA�VEL PACK Depth of Grout Seal <br /> El CATHODIC PROTECTION OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ,�' ? l 'Q <br /> ❑ GEOPHYSICAL 6�2Surface Seal Installed By: ! S l ML <br /> PUMP INSTALLATION: Contractor S, GI <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done a <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 forwhich 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 /> will call for a Grou n nor �routing�and a final inspection. <br /> Signe Cit_ Title: _�J�f\f . Date: �6 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted By Date X,f, <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT to PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑.July 1 &Received By July 31 <br /> �— REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS d, <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER -- — .,y t`} -- — — — — <br /> Y <br /> OTHER <br /> o d ,Shyla -30 00 <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 /> r� <br />