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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) � : WATER QUALITY t^� <br /> Application is hereby made to the San Joaquin Loa I Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with SaJoaquin ounty Ordinance o. 1862 and the rules and regulations`of'the San Jo quin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name ��'�� K Phone 2 <br /> Addressr� .__ City <br /> Contractor's Name ` : f� License#i�.c Business Phone <br /> Contractor's Address 4559' rgency Phone r� 11 .` <br /> ` Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes oC No <br /> TYPE OF WORK (CHECK): `NEW WELL —DEEPEN 19 RECONDITION❑ ' DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION- PUMP REPAIR 11 <br /> REPLACEMENT❑ <br /> 1 DISTANCE TO NEAREST: Septic Tank " ewer LinesPit Privy w <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 /> 07 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ca 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 s 61e<Pi&J <br /> Type of Pump = �"�,��/ / __ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Donefj <br /> PUMP REPAIR: 0 State Work Dane 0 <br /> DESTRUCTION OF WELL: Well Diameter Approxi to Depth �/ d <br /> Describe Material and Krocedure - 4l 14 <br /> t <br /> I hereby certify that I have pre4aretl 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 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 for which this <br /> permit is issued, I shall employ 1pers}ns subject to workman's compensation laws of California." <br /> f will cal for a Grout Inspetic)prior to grouting and a final inspection. <br /> Signed X" Title: QW N 't"!+p Date: <br /> (Draw Plot Plan on Reverse Side) ,( <br /> FOR DEPARTMENT USEfONLY,,, ,a <br /> -PHASE I - y <br /> Application Accepted ByDate 977_� r-2 <br /> Additional Comments: # 1 ' <br /> ._ -r � <br /> Phase 11 Grd t�}nspection as I lFinal Inspection 3 <br /> inspection By r >I Date Inspection By s F Date - <br /> !f} r # <br /> Fee 15 Due: ❑ ANNUALLY ❑ PERI. . ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &R ived B July 31 <br /> - f _ BILLING REMITTANCE �,/ $ REMIT <br /> B SE' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE , REMITTED AMOUNT <br /> FEE L � I <br /> ..� r #J_5 A9 c_ <br /> LESS lot <br /> PRORATION G+ {, f f•4' <br /> r- <br /> PLUS <br /> PENALTY <br /> x <br /> OTHER <br /> OTHER v r . <br /> t <br /> Received by - Date I - Receipt No Permit No. 4 Issuance Date _ Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />