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IM Applications Will Be Processed When Submitted PropertyCompleted.i3eSure 1oSlgn rnuxpplioacton. <br /> F(3#�64,—CE 0SE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> _ ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ` <br /> Appl ication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> xact Site Address f9 (.0 (0 W• I City/Town A C <br /> Cit t22 0 V <br /> in Tia V 1' � e. t t e v^- R d S IF <br /> Owner's Name Q 1 'F r� o �+ d 7niaC- Phone <br /> Address:. I77ti/% JJ City <br /> Contractor's Name4l� r+ ' icense#���1 '�3 Business Phone 73 (o& — /L.17F }- <br /> Contractbr's Address��� 1 I� rZ/.k�e dsCLvr�2cz— Emergency Phone SiS° Gl P <br /> Is Certifibate of Workman's Compensation Insurance on File With SJLHD4 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ --'1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank IUD 0 e_ Sewer Lines -Vex/4- Pit Privy 1L9d•� � <br /> Sewage Disposal Field rTJG rcJ 0— Cesspool/Seepage Pit /Ud Nom - Other <br /> _ Property Line Private Domestic Well AoPublic Domestic Well AJe__ <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND IJI STRIAE CABLE TOOL _ Dia. of Well Excavation <br /> N <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing eL ` <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �+'+► <br /> ❑ DISPOSAL ❑ OTHER Other-Information S <br /> ❑ GEOPHYSICALt Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r u C <br /> Type of Pump � H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Dane , <br /> I <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 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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi call for a Grout I Spec to prior to grouting and a final inspection. <br /> Signed!X R, Title: Date: . <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Yo�� Date <br /> Additional Comments: <br /> PhaseJ1 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date AS Inspection By4iv.d <br /> y Date — <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January l &ReBy January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE RE-MpIITQTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -30 o s r <br /> Received by I 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 />