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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TheApplication. <br /> FOR OFFICE USE: i I <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> - <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the SJoaquin Local Health District fora per <br /> an mitto construct and/or install thework herein described.This application is <br /> made in compliance w'th San Joaquin C unty Ordinance No. 62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Sit Address � �r �� City/Town J <br /> OwnerNo"me a j&(J I Al 0 Phone 'Fez- —c0 8 p 91 <br /> Address C <br /> � <br /> �;Ao City <br /> Contractor's Name License # 3OZn Business Phone <br /> Contractor's Address L� ' �✓ 2� Emergency Phone �V' Z yg— <br /> 1 <br /> *Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL_❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ QA <br /> w WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 r�� <br /> REPLACEMENT`S V" <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 <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 /> t ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ./ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor V J�,Lft <br /> Type of Pump r S PJB H.P. —� <br /> PUMP REPLACEMENT: �I State Work Done Nacl <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: I ° Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> P - <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 of the work forwhich this permit <br /> k is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> t ill <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 shafIl employ persons subject to workman's compensation laws of California." ` <br /> will call for a Grout lIns a ion prior to grouting and a final inspection. <br /> Signed X ,i Title: Dale: <br /> (Draw Plot Plan on Reverse Si <br /> t, FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date /�—a3 <br /> Additional Comments: <br /> Phase It Grout Inspection b' h a section 1 <br /> Inspection By JF s Date Inspection By 5 C4` �3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July_31 <br /> IM Y REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> h DATE DATE REMITTED AMOUNT <br /> FEEj a � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ecFY eived 1 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 />