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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) <br /> -�• -. Eo� , ENVIRONMENTAL HEALTH PERMIT PUMP&WELL + <br /> f <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. 186`2 and the rules and regulations of the San Joaquin cal th District. <br /> Exact Site Address City/Town <br /> Owner's NamePhone <br /> Address -1 rs1W da 44 City <br /> Contractor's Name License#!g3 f a.�Business Phone _ 76 7 a <br /> Contractor's AddressEmergency Phone .._ <br /> 9 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION {S PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Fieldg - 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 /> ❑ DISPOSAL ❑ OTHER Other-Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor " . A^� <br /> Type of Pump BSc; '21 H,P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ® State Work Done —2-7-9%4�41 Ra� i+'%, Alv"� Win/ --- <br /> DESTRUCTION OF WELL: Well Diameter IF Approximate Depth r <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 1 <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 persons subject to workman's compensation laws of California." <br /> I II call for a Grout Inspect' n ri to gr a�nld'a final inspection. <br /> uti <br /> Signed X itle: ��� Date: <br /> (Draw Plot an on Reverse Side) <br /> if <br /> FORD ARTMENT USE ONLY f <br /> PHASE Ir�7t <br /> Application Accepted By Date <br /> Additional Comments: t <br /> Phase It Grout Inspection hell inal 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 July 31 <br /> BILLING REMITTANCE $ REMIT # <br /> BASE - EXPLANATION - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE T5�� <br /> LESS p� <br /> PRORATION <br /> PLUS # <br /> PENALTY Jill <br /> OTHER <br /> OTHER ; <br /> Received by Date Receipt No. Permit No, Issuanc4 Date Mailed Delivered �JJ a <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES .- 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CK9 201 ' <br />