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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. IN <br /> FOR OFFICE USE: APALICATION <br /> xf (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&.WELL <br /> b, (COMPLETE INTRIPLICATE) 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 /> made in compliance with S/ Jo In Count Ordinwice No_ 1862 and t ul and re lations f the n Joa n ocal H aIth.District. <br /> Exact Site Address Ei�pR 7 �Jc/� o zi4t/ �M ire isa_,�e �7Tow nl ��iv KaC <br /> 4 <br /> Owner's Name ',�u Phone _477 !T— <br /> Address City Q <br /> Contractor's Name /2 License#�_/ Business P one_ <br /> Contractor's Address 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 u DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ l; <br /> REPLACEMENT[] Imo+ <br /> DISTANCE TO NEAREST: Septic Tank �/l)__f _ Sewer Lines Pit Privy -- <br /> Sewage Disposal Feld Cesspool/Seepage Pit Other <br /> F Property Line/Q4___ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ` n <br /> © INDUSTRIAL ❑ CABLE TOOL Dia, of'Well Excavation l _ <br /> 0DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing es1� d <br /> ❑ DOMESTIC/PUBLIC © DRIVEN Gauge of Casing �/osg �G !ey <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> E ❑ CATHODIC PROTECTION ROTARY Type of Grout a ,rA4 ane. <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> r ❑ GEOPHYSICAL 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 Depth <br /> Describe Material and Procedure <br /> f <br /> I 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 ownor 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 /> r' 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 bl'ect to workman's compensation laws of California." <br /> I wit for a Grou nspe ' n p r grouting and a final inspection. <br /> ` Signed X Title: Date: JVr !3 Q <br /> (Draw Plot Plan on Reve a Side) <br /> OR DEPARTM NT USE ONLY <br /> PHASE <br /> Application Accepted By `� Date vk <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> I Inspection By Date C�-�a`'s Inspection By Date <br /> Fee Is Due: ElMvANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> t EEE 4/ <br /> LE55 <br /> r PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />