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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 /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joa uin County Ordinance o. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 2. F 2 t` City/Town f'e'd of i& -Q <br /> Owner's Name 1� r*t r'/ ✓ Phone - 9 <br /> ^ 001 <br /> Address 2 7— S• `70' City/ ',r <br /> h G M ,lye, CoePt <br /> Contractor's Name N 01`_ ��r�,iA'��! �J s to 40 License# 3 r7�S715t_ Business Phone , �' "44 <br /> Contractor's Address PP� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes_� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 /> 0 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Y <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing W 6 1 V m <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ <br /> 1:1CATHODIC PROTECTION ❑ ROTARY Type of Grout g, Z1 <br /> ❑ DISPOSAL ❑ OTHER Other Information `�'��✓ER(..j'i AML INIE_A'L HEALTH <br /> ❑ GEOPHYSICAL Surface Seal Installed B I ;..l� R ''''`E" <br /> Y� �-��t v I s 9 f �t=a't c•���� <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump H.P.— v'r v 1 <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 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 will call for a Grout Inspectio rior to grouting and a final inspection. <br /> Signed X �`- Ee/'Title: _: V,4 4!r AO A44#47e"A'``u Date: :P <br /> (Draw Plot Plan on Reverse Side) <br /> F DEPARTMENT USE ONLY <br /> PHASE I � <br /> Application Accepted By Date <br /> Additional Comments: JVr <br /> Phase II Grout Inspection ftas III Fin Inspection <br /> Inspection By Date Inspection Date i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> s -9 Q� Z7S ? <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.Box 2009 STOCKTON,CA 95201 <br />