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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR 9FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (C MPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application ig.,__, <br /> made in compliance with San Joaquin County Ordinance No. 1862 nd the rules and regulations of the San aqui Local HealtUjDistrict. <br /> Exact Site Address �o City/Town �tlTae/1 975'_K-9 4C <br /> Owner's Name / R.2 <br /> Phone <br /> Address City <br /> Contractor's Namea # <br /> (cense ` Q <br /> �`' ��j,3//f� Business Phone g 4/ <br /> Contractor's Address D c V Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ JI _ No (� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ If <br /> DISTANCE TO NEAREST: Septic Tank <!j Sewer Lines SD f Pit Privy <br /> Sewage Disposal Fiend Cesspool/�eepage Pit Other <br /> Property Line�O. t-Private Domestic Well/K Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1.2 �j <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing 4 `j <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C 4Lf,S__ c cn oe <br /> ❑ IRRIGATION 9 GRAVEL PACK Depth of Grout Seal So <br /> ❑ CATHODIC PROTECTION X ROTARY Type of Grout e0E--XA6 r` <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: - c�e,,Ar2 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. .t <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 /> 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 signatur certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall empl persons sub ct to workman's compensation laws of California." <br /> I will7��J <br /> tInspe n prio outing and a final inspection. <br /> Signed X Title: F Az Date: <br /> (Draw Plot Plan on Reverse Si e <br /> If FOR DEPARTMENT USE ONLY <br /> PHASE I �2vQk (pro <br /> Application Accepted By A )Date 7 2 O <br /> Additional Comments: <br /> I Grout Inspection "January ection <br /> Inspection By Date .. InspectionDate <br /> Fee Is Due: 11ANNUALLY ElPER UNIT ❑ PER SITE 11EACH ElJanuary 1 8 Received By 31 ❑ July 1 &Received By.July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE > 7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />