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ApplicationsWill BeProcessedWhenSubmitted Properly Completed. Be Sure To Sign The Application. <br /> x FORrOFFICE USE: APPLICATION , } , . ,q <br /> (For Non-Transferable, Revocable, Suspendable) 11��-t�E• `P& <br /> ENVIRONMENTAL HEALTH PERMIT PUMP WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count rdinance 1862 and the rules and regulations of the San Joaquin Lo al Health District. <br /> Exact Site Address d City/Town <br /> Owner's Name Phone f <br /> Address — 76.4,r_�� '. City <br /> Contractor's Name f .4W to �( F�� aiLi_1���� License#�Z�,��� Business Phone / <br /> Contractor's Address -Ig-oa ,s�A,/,/, ���1 _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN,4 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines- ��Y��- Pit Privy N <br /> Sewage Disposal Field� � �.f Cesspool/Sgepage Pit Other �-- <br /> Property Line Private Domestic Well -( Public Domestic Well �— <br /> INTENDED USE TYPE OF WELL <br /> © INDUSTRIAL Dia. of Well Excavation_Ild <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing`. _ w <br /> ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing 16,0 �r �.0 <br /> © IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ..Cc 6L('0-'0 <br /> PUMP INSTALLATION: Contractor Tit <br /> Type <br /> of Pump H.P. tai: <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: E ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth t <br /> Describe Material and Procedure j <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wi0San 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 I11'r 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 su Nect to workman's compensation laws of California." <br /> I will cal aroui I ectio rior outing and a final inspection. r <br /> Signed X Title: j4q ry L Date: <br /> (Draw Piot Plan on Reverse§14e) <br /> ,:OREPARTM T USE ONLY _ <br /> PHASEI <br /> Application Accepted By Date 7p <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date+ Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT la PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 jo <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY d ' <br /> OTHER <br /> OTHER <br /> o S <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 />