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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 Nan-Tran§ferable, Revocable;Suspendable) PUMP&WELL • { <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) FWATER 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 /> made in compliance with San Joaquin County Ordinance-No.1662 and 1he rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address . <br /> City/Town <br /> `-'S.3 <br /> Owner's Name Phone `-' - � � �'� q <br /> Address 66 <br /> .. Y City G� "• �„1`� <br /> Contractor's Name �-— License#'753Business Phoned r' t <br /> Contractor's Address . _/6 Imo, 1 t ;`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 /> Y <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy } <br /> • Sewage Disposal Field Cesspool/Seepage Pit Other j <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑_ INgUSTRIAL ❑ CABLE TOOL -Dia. of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER r Other Information <br /> 1 <br /> ❑ GEOPHYSICAL a Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 3y ,e .►• <br /> Type of Pump _ - f —' H.P. 1` <br /> PUMP REPLACEMENT: ❑ State Work Done 7. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <br /> s <br /> 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 tcillowing:'tl 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 sup-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 workman's compensation laws of California." " <br /> 1 will a Grout Inspe ion prior to grouting and a final inspection. } <br /> Signed �¢� Title: - - Date: 0- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY [ <br /> PHASE <br /> Application Accepted By---- Date <br /> Additional Comments: <br /> Phase II Grout Inspection P as I F' al Inspection <br /> Date Inspection By DatInspection.By.low Date 7-r-3 <br /> .Fee Is Due: ❑ ANNUALLY' _ ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January'31 — ❑ July 1 &Received By July 31 <br /> _..BILLING Y ,. REMITTANCE. $ REMIT - <br /> BASE. - EXPLANATION Lit PATE DATE REMITTED AMOUNT DUE CHECKED <br /> �} AMOUNT <br /> FEE V <br /> LESS a _ <br /> PRORATION M <br /> PLUS <br /> PENALTY r <br /> t <br /> OTHER <br /> i r <br /> OTHER <br /> 1 <br /> Received by Date Receipt No. Permit No. - Issliance DaII6 Mailed .Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />