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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR.OFFyCE 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 made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Jo qui n ounty Ordinanc o. 1862 nd the rules and regulations of the San Jo in Local Health District. <br /> Exact Site Address /"Ql 'C-� City/Town <br /> Owner's Name _/_ '�/!cC q CUR. C,p Phone — e4 7 �^ <br /> Address _AAS 6 R73 s- v�+�. __._. _g7!!_- _ City �G!y 7-& <br /> Contractor's Name �a!cu 274,e E- I=i i�&njp License tf Business Phone -7 2'3.;L- <br /> Contractor's <br /> '3.;L-Contractor's Address OCT S M ha Emergency Phone ;7 -?�. <br /> Is Certificate of Workman's CompensationIns rance on File With SJLHD? Yes_X_ No R , <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ IN <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /0 Q Sewer Lines t i? Q' Pit Privy <br /> Sewage Disposal Field /v 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 /> _P <br /> DOMESTIC/PRIVATE E] DRILLED Dia. of Well Casing rho <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I4 f <br /> ❑ IRRIGATION X RAVEL PACK Depth of Grout Seal G <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout 6,P,4 7"c,c?t -p <br /> ❑ DISPOSAL ❑ OTHER Other Information S 2 y <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Oz-e-,el-P <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done __z <br /> PUMP REPAIR: ❑ State Work Done RC1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> G <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 Cn <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." a <br /> Contractor'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 persons subject to workman's compensation laws of California." <br /> I will call for a Grout In pe tion prior to grouting and a final inspection. <br /> Signed X Title: (/'SzZl� - Date: +� <br /> 3 <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> PHASE q <br /> �. Application Accepted By 0q <br /> Date — SSS <br /> Additional Comments: <br /> se 11 Irr Inspection 5By <br /> II Fi n <br /> Inspection By Date �3 T Inspection y <br /> Y <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH 0 Ja &Receary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITT AMOUNT DUE CHECKED !` - <br /> r AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit-No. Isdiance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: . ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />