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Applications Will Be-Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F09'.Al`FICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> 1 made in compliance with San Joaquin County Ordinance No.1$62 and the rules and regulations of the San Jo uin Local Health District. <br /> Exact Site Address�/ ?f Al F�6 / -� y��r 1/� City/Town 5A q __ <br /> Owner's Name l"i(1 Qr._��_�",��sr��4�J Phone <br /> Address City <br /> Contractor's Name License# Business Phone 2PI b <br /> 4 Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR r <br /> REPLACEMENT❑ / 1 <br /> DISTANCE TO NEAREST: Septic Tank c540 Sever Lines t46 *_ Pit Privy <br /> # Sewage Disposal Field�6(� Cesspool/S?opago Pit Other <br /> r <br /> Property Line Private Domestic Well Public Domestic Well <br /> r <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 f <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> F ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> f. - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Proceduregr <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 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 /> t 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 empiloy per ns subject to workman's compensation laws of California." , <br /> I will 11 fora 99ut pect for to grouting and a final inspection. <br /> Signed X Title: A( Dale: _1Y ZiSl AIV— k.1 7 <br /> ► (Draw Plot Plan on Revers ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By "u`-' Date�l� <br /> Additional Comments: <br /> Phase 11 Grout Inspection5 Inal Inspection <br /> Inspection By Date Inspection B Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> k REMIT <br /> BILLING REMITTANCE $ <br /> BASE i EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ' <br /> � AMOUNT <br /> FEE <br /> LESS <br /> - PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t <br /> k <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered / �t <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.9o:2009 STOCKTON,CA 95201 �^' <br />