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I Applications tAlXBe Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r FOR OFFICE USE: APPUCAI ION <br /> r (For Non-Transfera ble,'Revocable,Suspendable) <br /> _ PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I Application is hereby made to the San Joaquin Local Health District fora permit to construct,� I t work herein described.This application is <br /> made in compliance with San Joaquin County Ordi a ce No. 1862 and the rules annd�r�ei;tfa�o hAapn J aquin Local He th District. <br /> �. Exact Site Address � c7L +� � gs� ? - ^� �^ l <br /> Owner's Name •L Phone <br /> Address ry <br /> City Ot'rv}l-eo - <br /> Contractor's Name License#t2?? 4 Business Phone_ <br /> Contractor's Address d Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL 0, DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> ' WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ If <br /> DISTANCE TO NEAREST: Septic Tank 4) f Sewer Lines 166 I Pit Privy <br /> Sewage Disposal Field/D�T..�. Cesspool/Seepage Pit �^-�-^— Other <br /> t <br /> Property Line Private Domestic Well Public Domestic Well ----� - � <br /> INTENDED USE TYPE OF WELL fr <br /> ❑ INDUSTRIAL CABLE TOOT_ Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> j ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> R.IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 6-5 14 Aire <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> a DESTRUCTION OF WELL: Well Diameter Approximate Depth Q <br /> Describe Material and Procedure <br /> 4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I 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 the work for which this permit 'djl <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> QContractor'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 p r ns subject to workman's compensation laws of California." <br /> I wit for a G out 5 ecti for to routing and a final inspection. ` �o <br /> 3 <br /> Signed X Title: snl/ Date: f <br /> (Draw Plot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 C} <br /> Application Accepted 8 <4Date 'a-7 ( 1 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNET ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE <br /> EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> a <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ! OTHER <br /> OTHER - <br /> 21 v`t.7� 77'1_r a <br /> Received by Date Receipt No. Permit No. I5 uance Dbte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 952 <br />