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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) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqui�nt Count 0/rdinance No. 1882 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address_{ Q � Jd, Llhtx� City/Town ip��t► <br /> Owner's Name !/ cCf Phone 2 / <br /> Address City ��r Ccs ) <br /> Contractor's Name License#:cf9Z/ Business Phone 7 f <br /> Contractor's Address Emergency Phone PZ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ' ^s <br /> TYPE OF WORK (CHECK): NEW WEI DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOD}A&b PUMP REPAIR❑ <br /> REPLACEMENT❑ ` <br /> DISTANCE�TO NEAREST: Septic Tank Se7r Lines,i x Pit Privy <br /> l /, W�,i� �S�wage Disposal Fid s Cesspool/Seepage Pit Oth <br /> Property Line Private Domestic Well ��� Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 4,2 <br /> EbDOMESTIC/PRIVATE PIQDRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 671 r <br /> ❑ CATHODIC PROTECTION PLROTARY Type of Grout _,�o�✓ i�� r <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL n ,r Surface Seal Installed By: Ian <br /> PUMP INSTALLATION: Contractor_ /t �f��"�, V� <br /> i____ - <br /> —_ Type of Pum ?tc d H.P.—,/ - - <br /> PUMP <br /> .P-PUMP REPLACEMENT: ❑ State Work Done ) <br /> PUMP REPAIR ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> IDescribe Material and Procedure <br /> heI reby 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 forwhich 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 t- <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t � <br /> I w' call for a Grout Inspection prior to- uting and a final inspection. 1 <br /> Signed X Title: . <br /> (Draw Plat Plari on Reverse Side) <br /> --FOR ISEP.ARTMENT,USE ONLY,, <br /> =...,i_.._.—..r..r.. .. y .. <br /> PHASE <br /> Application Accepted By Date 13 - ! <br /> Additional Comments: <br /> * P lase 11 Grout Inspection Phase lit Final Inspection <br /> Inspection Bye Date 7� '. Inspection By, Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑:July 1 &Received By July 31 <br /> - Re -----r -- —BILLING REMITTANCE . ., ..$..,�r...� r REMIT ' <br /> BASE EXPLANATION '� AMOUNT DUES "`' CHECKED-.I <br /> _ DATE— —DATE _ ,REMITTED AMOUNT <br /> FEE 00 k Q <br /> LESS <br /> PRORATION t - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> f �� <br /> Received by Date Receipt No. ,Permit No. s anc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />