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Applications Will Be Processed When Submitted Properly Completed. Be.Sure To Sign The Application. <br /> FOR OFFICE USE: Ca IKP/a 44 APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 an�d1 the rules and regulations of the San Joaqui Loc I Health District. <br /> Exact Site Address a�G 31G E? r�rn ,� ZI?.�r City/Town 4 <br /> Owner's lame J54✓+04, ceoA_.r Phone <br /> Address _- xo 91l., Aa City 4 0 _ <br /> 6 1r <br /> Contractor's Name lel License#_ ffl— <br /> ��L. Business Phone <br /> Contractor's Address iuj 4L Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes—K No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRPd <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy W <br /> Sewage Disposal Field _ Cesspool/Seepage Pit Other W <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a,- <br /> Type of Pump �`�Gl X74✓� /�/,G..._ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done 4k"iv4P .' 9 A1& _ <br /> DESTRUCTION-OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 performance ofthe 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 far which 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 or and a final inspection. <br /> Signed `� tle: Date: <br /> (Draw Plot PTan on Reverse Side) . <br /> FO DEPARTMENT USE LY <br /> PHASE I Q q <br /> Application Accepted By— <br /> Additional <br /> y Date U ?/ <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By duly 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $PATEDATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI$ERVICES 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />