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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL (((III t <br /> ENVIRONMENTAL HEALTH PERMIT 4 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local HealthDistrictforapermittoconstructand/or install theworkherein described,This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the Sa�Joaq�ufin Local Health District. <br /> Exact Site Address City/Town 1�c. <br /> Owner's Named Phone <br /> �- 3.3 7 <br /> Address City G p <br /> Contractor's NameLicense Business Phone 3 <br /> Contractor's Address f a `�7 Emergency Phone te�:. �l �-�� ' <br /> Is Certificate of Workman's Compensation Insu nce on File With SJLHD? Yes ✓ No t <br /> TYPE OF WORK'(CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO,NN O <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP R€PAIR❑ C� i <br /> REPLACEMENT❑ // ! c7� t T I <br /> Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Lo ``�-` Sewer Lines a d <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 4 <br /> Property,Line /OO Private Domestic Well Public Domestic Well <br /> INTENDED USE i TYPE OF WELL �I I <br /> ❑ 1 DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> liQ DOMESTIC/PRIVATE ❑ DRILLED }w' '; 'Di 'o <br /> - <br /> ❑ DOMESTIC/PUBLIC <br /> �❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ! (] GRAVEL PACK Depth of Grout-Seal <br /> ❑ CATHODIC PROTECTION 0KROTARY `,j Type of Grout - <br /> 1:1 DISPOSAL + 7--13- rTHER "� Other lnforrrlatibn•- <br /> ; Install-0 <br /> SI 1 s `Surface.Se)l InstalleUdBy: <br /> El GEOPHYSICAL <br /> S <br /> PUMP INSTALLATION: iF3+,Contractor <br /> Typefi lot Pump H.P. <br /> PUMP REPLACEMENT: i ❑ St�te Work Done <br /> ❑ State Work Done �i <br /> PUMP REPAIR:' i I I _ - s <br />! DESTRUCTION OF WELL: + ��—Wel)DiameterApproximate'Depth <br /> } i a Describe Material and Procedure.. <br /> I hereby certify that Iha a prepared this application and that the work will.tie done in accordance with San Jaagnin-Countyk <br /> ordinances, state laws,and rules and regulations of the San Joaquin Local Health District. <br /> Horne owner or licensed agent's signature certifies the following:'1 certify that n the performance of the work fpr 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 folioviring:"I certlfy.that in the performance fol the work for which this ) <br /> permit is issued, I'sha6'%mploy persons subject to workman's co�lipensation Laws of California." .;�sr ! <br /> i. i w' al for a Grout spection prior to grouting and a final InspecNen. <br /> Signed X i� ��'I/� Title: _ Y Date: <br /> (Draw^ Plot Rlart`on Reverse ide)At.` <br /> 4 T i FOR DEPARTMENT USE ONLY <br /> j PHASE I j Date �< <br /> Application Accepted By <br /> Additional Comments: <br /> ha III Final Inspection <br /> Phase II Grout Inspection <br /> I Inspection By Dat <br /> Inspection By Date <br /> ❑ ANNUALLY - ❑ PER UNIT []'PER SITE ❑ EACH ❑ January 1 &Received By January' 0 July 1 &Received By July 31 <br /> Fee Is DueREMIT <br /> E BILLING REMITTANCE $ AMIIOUNT DUE CHECKED <br /> -BASE --EXPLANATION DATE DATE REMITTED AMOUNT <br /> D <br /> FEE l � <br /> LESS <br /> I PRORATION <br /> } PWS �--��.----'.-�---'--- <br /> PENALTY <br /> OTHER <br /> OTHER 1 <br /> k v <br /> • Received by Dale, Receipt No. Permit No. �- - .IsB ante Date ' Mailed- DelivereIt d - <br /> y4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />