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Applications Will Be Processed When Submitted Properly Completed. Be Su—re-T6 Sign The Application. <br /> FOR OFFICE USE:` APPLICATION <br /> rr (For Non-Transterabie, Revocable,Suspendable) PUMP&WELL <br /> u <br /> ENVIRONMENTAL HEALTH PERMIT 4. <br /> (CO PLETE IN TRIPLICATE) WATER QUALITY <br /> Applitation is hereby made to the San Joaquin Local Health Districtfora permit to consirdctand/o"r ins'ta'll the work,herein Vdescribed.This appls ationis <br /> mad�in compliance with San Joaqui County Ordinance No. 1862 and the'rules and,r�eg�lati of the San Joaquin Local Health District. ` <br /> Exact Site Add ress •,C'I!1.rt�/:o.f:g_if t t f/Town I&ZtJ C&ZdW4G1 +" <br /> Owner's Name Phone <br /> Address �: �• 4 City . CL <br /> Contractor's Name VO4Llu -',�License#_60?0 Business Phone <br /> Contractor's Address S S •Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ti <br /> TYPE OF WORK (CHECK): NEW WELLA ' DEEPEN ❑ --;RECONDITION❑' DESTRUCTION❑ t WELL CHLORINATION ❑ WELL'ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR CA <br /> REPLACEMENT❑ j,^', <br /> DISTANCE TO NEAREST: Septic.Tank /QV _ Sewer Lines Pit Privy <br /> - Sewage Disposal Field / f Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE 4' TYPE OF WELL <br /> 1 ❑ <br /> INDUSTRIAL . _ ❑ CABLE TOOL Dia. of Well Excavation— <br /> i' <br /> DOMESTIC/PRIVATEC1DRILLED Dia. of Well Casing <br /> ❑ DOMESTEC/PUBLIC AIS' ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ;; <br /> GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTIONROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor <br /> ii Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: qt ❑ State Work Done <br /> DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> I „ Describe Material and Procedure <br /> IL 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 shalt employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout In ction prior tag outing and a final inspection. <br /> Signed X - Title: Date: cs <br /> 0"ra Plot Plan on Reverse kid ) <br /> FO EPA TMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date <br /> .� <br /> Additional Comments: <br /> Pha I rout Inspectionl_ Phase III Final Inspection <br /> Inspection By Date 7�/ _ Inspection By 1 }` Date <br /> Fee Is Due: ❑ ANNUALLY :ill[] PER UNIT ❑ PER SITE . ❑ EACH'- ❑ January 1 &Received By January 31 ❑ Ju#y 1 &Received By July 31 <br /> ` 7 REMIT <br /> F - BASE 9p EXPLANATION- - -BILLING REMITTANCE $ AMOUNT DUE - CHEGKED . <br /> i' DATE DATE REMITTED AMOUNT <br /> r FEE- 5 .r - <br /> LESS. �- <br /> PRORATION iI <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> Received by. T Date' .Receipt No.l... _ _ Permit No. c� Iss an Dale" Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO; .ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />