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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: /// APPLICATION <br /> 4' l� 014A,�(p` (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 for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin ou. Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name6/ IPA d1k Lof <br /> Phone <br /> Address o City ' <br /> Contractor's Name uw License# 3 Business Phone t�tnt may-F�b7� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SILHD1 Yes XNo <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑; PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ . <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> El INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> pr DOMESTIC/PRIVATE ❑ DRILLED ` Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVENGauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK a' Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ' Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump W.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP•REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL:—.&-- Well Diameter - ° - � Approximate Depth ` <br /> Describe'Material and Procedure <br /> 1 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 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." <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 ill all for a Grout InspegUr r g uti atinoWiosej� n. <br /> SignedDate: <br /> (Draw Plot Plan on Reverse Side) <br /> e <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE , n`- O� t1?oC <br /> Application Accepted By Date �� <br /> Additional Comments: <br /> i <br /> Phase II Grout Inspection ase III Final Inspection <br /> Inspection By m R Date Inspection By ate 7 IS�Yr <br /> i <br /> A r <br /> -Fee IS Due: ❑ ANNUALLY EI PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 July 1 S Received By July 31 <br /> 'BILLING REMITTANCE $ REMIT ` <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE ! DATE REMITTED <br /> AMOUNT <br /> FEE 41S <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER. <br /> V-13 1Y <br /> • Received by i - Date -Receipt No. Permit No, - Issuande Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />