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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: 'APPLICATION <br /> { - 40AP`/' (For Non-Transferable, Revocable,Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL i <br /> (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 des ibed.This application is <br /> made in compliance with San//Joa urn County,0rdil,n��nce No. 1862 and th le and regulations of the San Joaqui Loc Health District. <br /> Exact Site Address b Vo <br /> f�J4ltstl�S"� t✓ <br /> ,/ ''-- qt City/Town <br /> Owner's Name A4 ow 6/� i�J P't - Phone <br /> 01 <br /> Address7A16,0 � City < <br /> Contractor's Name License# � <br /> _R l3usiness Phone -2- 7G <br /> Contractor's Address ow Emergency Phone <br /> II <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL E] DEEPEN ❑ RECONDITION Lu DESTRUCTION❑ ° <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS a <br /> - t• <br /> REPLACEMENT❑ I <br /> a <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 4 <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 ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> i ❑ GEOPHYSICAL Surfa Seal Instail y: 1 <br /> PUMP INSTALLATION: . Contractor r, G <br /> t <br /> Type of Pump AC -.e H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done _ <br /> DESTRUCTION OF WELL:, Well Diameter pproxim e Depth _ <br /> Describe Material and Procedure 1J <br /> I hereby certify that 1 have prepared this application and that the work will be done in acco`r`dance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. h <br /> i Home owner 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 /> 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 shalt employ persons subject to workman's compensation laws of California." <br /> IIwill call for.a Grout Inspection ri o gr Ing d a final inspection, <br /> Signed Xv� e: ;�w C, Date: f <br /> (Draw Plot PI on Reverse Side) <br /> 4 <br /> FOR DEPARTMENT USE ONLY^ <br /> PHASE <br />'h Application Accepted Byob F� !A!SGL_ 2 Date <br /> Additional Comments: <br /> Phase II Grout I spection _, 4h;aaseM:a1tpectionInspection By ate " InspectionBy ti <br /> f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> BILLING REMITTANCE $ REMIT - <br /> Y'BASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED t <br /> i4 d AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER s u <br /> OTHER x _ -- <br /> I Tal-g) <br /> Received by Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />