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—A pplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. :1ST <br /> FOR OFFICE USE: APPLICATION . <br /> (For Non-Transferable , Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE ) — ATER_QUALITY Zp 3 2?� _— eq/ <br /> Application is hereby made to the San Joaquin Local H@alth District Lor S permit to construct and/or install the work herein described.This application Is <br /> made in compliance wi h an Joaquin County Ordinance No. 1862 and e r les and regulations of the San 4DpqOn Local Health District. <br /> Exact Site Address City/Town Ma <br /> Owner's Name fjf1 '" ,t s Phone <br /> Address — City <br /> Contractor's Name # T51—c�5 Business Phoria" �'!q 3'(1S <br /> Contractor's Address ' ''x fn r`z ' r Emergency Phone <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ ' RECONDITION❑ 'DESTRUCTION -' <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ --p <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank , Sewer Lines ,� a 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 `E1' <br /> ❑ 'CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL , . Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ t <br /> PUMP REPAIR: ❑ State Work Done t <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 performanceof thework lorWhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensatioh laws of California." <br /> I will call for a Grout Inspection prior to grouting and-a final inspection. .{.—+ <br /> Signed X �._. �. <br /> 9 $ �� r� Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> iFOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ByS�A>�- - Date <br /> Additional Comments: <br /> P as II Grout Inspection Ph as III Final Inspection C <br /> _ Inspection By Date QT.��1 g 2 Inspection By Date2u p2 - <br /> --Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -- ❑ PER SITE 1:1 EACH ❑-January 1'&Received By January 31 -El July-1 &-Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> 'BASE - EXPLANATION- - , AMOUNT DUE. CHECKED ' -- <br /> DATE DATE .REMITTED AMOUNT <br /> wFEE <br /> LESS <br /> PRORATION ' <br /> PLUS - <br /> PENALTY <br /> OTHER . <br /> OTHER <br /> Received by Date Receipt No. S — AlermiLNo.— ; __ N- suanc te_ Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - Y <br />