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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE: APPLICATION <br /> y' (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r �. . - .� <br /> (COMPLETE IN TRIPLICATE) WATER - <br /> Application is hereby made to the San Joaquin Local Health District for a-permUALITY -4V <br /> Q it to construct and/or install the work herein described,This application is <br /> �E?t„ <br /> made in compliance with an Joaquin County nOrdinance No. 1862 and the rules and regulations of the San Joaqu n Local Health District. <br /> Exact Site Addr'esss1 ���� {slcrSe`t kT��,l.)� , City/Town �PC�� <br /> Owner's Name 1 xcz `o�l-.....ca. Phone ,� �•' 2- <br /> Address ` ' g� _ City .t✓.4\�L� a 0,U <br /> Contractor's Name p1 r' License# '2,P '15'G'. Business Phoneme <br /> Contractor's Address UI —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 El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ - -OTHER ❑ r ,PUMP-INSTALLATION ❑ •".PUMP. REPAIR <br /> REPLACEMENT❑ , <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field /0 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic•Well Public Domestic Well <br /> INTENDED USE .i TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL t , r.F Dia. of Well Excavation-__..L � _ - <br /> ❑ DOMESTIC/PRIVATE ❑'DRILLED Dia. of Well Casing Com" <br /> 04 DOMESTIC/PUBLIC* ❑ DRIVEN Gauge of Casing _ P13Cr 9�r, <br /> ❑ IRRIGATION D GRAVEL PACK,_,,,. Depth of Grout Seal SCS <br /> ❑ CATHODIC PROTECTION ® ROTARYµ Type of Grout XIE?yl�ronA:e <br /> ❑ DISPOSAL ❑ OTHER Other Information � <br /> ❑ GEOPHYSICAL' . t- Surface Seal Installed By: <br /> PUMP INSTALLATION:. Contractor <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 D pth ''��Q <br /> �. Describe Material and Procedure 0 <br /> I hereby"certify that l 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 certlfies the following:"I certify that in the performance of the work forwhich this permit �} <br /> is issued, I shall hot emplby'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 workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed ` ,<- a.,.fl. . _ Title:9-n.Q,.k- _ Date:., <br /> (Draw Plot Plan on Reverse Side) t <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By ° Date �� a <br /> Additional Comments: <br /> Ph se II Grout Inspection , Ph III Final Inspection t <br /> r <br /> Inspection Sv .Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, ❑ PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July!31 •v. <br /> F REMIT <br /> BILLING '-REMITTANCE $ <br /> 'BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT f <br /> FEE 4 3 <br /> LESS ir <br /> PRORATION <br /> PLUS <br /> PENALTY s <br /> OTHER <br /> OTHER - - r�stp O + <br /> s <br /> ' 1 <br /> z'S--Z FS <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 />