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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ti <br /> �o0t, & (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r (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 herein described.This application is <br /> R% <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Jona ,uin Local Heal h District. <br /> t.._ t 4 , <br /> Exact Site Address 1D0 /1� £City/Town Q <br /> Owner's Name <,;r dit . j.l't ':, iaC4�[.Et r ' •:�. ,: Phone:' t•..,, <br /> Address City '�5�C,�a' �- <br /> Contractor's Name C_�h3 '�°* `'' License# L94- ?,T Business Phone•_" <br /> Contractor's Address ` s� t Emergency Phone' <br /> Is Certificate of Workman's Compensation Insurance on File Wit 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❑ I ]` <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 3 Pit Privy 1 <br /> Sewage Disposal Field Cesspool/Seepage Pit--M,i = Other CJJ <br /> Property Line Private Domestic Well. Public Domestic Well <br /> INTENDED USE TYPE OF WELL t <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 ❑ GflAVEL PACK Depth of Grout Seal t <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout t <br /> ❑ DISPOSAL ❑ OTHER Other Information Ai <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor crt� <br /> •:Type of Pump <br /> PUMP REPLACEMENT: State Work Done `' G2=411J +- <br /> PUMP REPAIR: -f'❑ State Work Done <br /> DESTRUCTION OF WELL: V11e11 Diameter Approximate Depth --- <br /> Deseribe Material and Procedure ■ `_ ��;"t <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof 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 forwhich this <br /> permit is issued, i shall employ persons subject to workrrtan's compensation lavas of California." <br /> I call for a Grout s ct In ri r to gr Ing and a final inspection. <br /> Signed• Etle: Date: <br /> 6f 1 <br /> (Draw Plot an on Reverse Side) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 } t t <br /> Application Accepted By Date-4--- <br /> Additional <br /> j -Additional Comments: <br /> Phase If Grout Inspection _ Phase III Final Inspections D <br /> Inspection By [)� 1 n Date Inspection By Date <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT ❑ PER SITE r ❑ EACH! ❑ January T&Received By January 31 ❑ July 1 &Recekved By July'31 <br /> s <br /> a.. BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 4. <br /> PENALTY, - f i <br /> OTHER ' <br /> 4 ' <br /> OTHER <br /> 4� 13& 1- 6- . <br /> _1 Received by Date- - - Receipt No:� - Permit-NoIss ante ate -Mailed Delivered <br /> -- <br /> APPLtCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />