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� .=x Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, " " f' <br /> FqA OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE.) WATER QUALITY lJ!� <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is U1 i <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ��. n LJ �, IRc� City/Town <br /> 17 <br /> Owner's Name Phone Jq — } <br /> Address City <br /> Contractor's Name License#� br"�7/_ Business Phone 1 <br /> Contractor's Address I O i &7;4 //CP Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes._ ___ No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER`C•e PUMP INSTALLATION K PUMP REPAIR D <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines i Pit Privy <br /> a <br /> Sewage Disposal Field -;- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well i-_ Public Domestic Well <br /> INTENDED USE TYPE OF WELL lit, <br /> ❑ INDUSTRIAL ❑ CABLE TOOL f _Dia_of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> X DOMESTIC/PUBLIC ❑ DRIVEN I Gauge of Casing tt} <br /> ❑ IRRIGATION ❑ GRAVEL PACK I Depth of Grout Seal + <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout {9 <br /> ❑ DISPOSAL ❑ OTHER Other Information !: <br /> ❑ GEOPHYSICAL # Surface Seal Installed By: � � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _4444;- H.p,! Ze!V <br /> PUMP REPLACEMENT: ❑ State Work Done Yt <br /> I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t <br /> Describe Material and Procedure t <br /> I hereby certify that_j-have prepared-this application-and-that thi work will-be done in eccordancelwWth San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for fvhich'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 fdr which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." ' . <br /> I will fo a Grout Ins tion prior to grouting and a final inspection. <br /> Signed Title: 4 Ae Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> I <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> Application Accepted By !' ' Date -7 7 ! <br /> Additional Comments: - <br /> Phase 11 Grout Inspection ase III Final Inspection <br /> Inspection By Hate Inspection By 0 ate <br /> Fee Is Due: El'ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Re eived By anuaryVII ❑ July 1 &R By July 31 <br /> i REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED I AMOUNT <br /> FEE <br /> rip <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ' <br /> 177 <br /> Received by Date Receipt No. Permit No Issuances Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />