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(. pplicationsWill BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. _ — <br /> FO,R oFF.Ir uta; <br /> APPLICATION <br /> qll L e. <br /> (For Non-Transferable, Revocable,Suspendable) t.0 <br /> r <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL R,,0�" <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> f Application is herebymadetotheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> t made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address C7 City/Town <br /> Owner's Name Phone 3 `S <br /> Address - City Zo e.fI <br /> Contractor's Name IIL4 puk-b, '� License# e 237 2 Business Phone `}�W1^ QC2S <br /> i <br /> Contractor's Address - C =I— A 7 gmergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION © -� PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> F DISTANCE TO NEAREST: Septic Tank 160 Sewer Lines /a0 Pit Privy .5U0 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line fPrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing' <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: <br /> PUMP INSTALLATION: x Contractor <br /> Type of Pump L�' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter G it <br /> 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 /> Home owner 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." a <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this t <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." t <br /> I will call for a Grout Inspection prior to grouting and a final inspection. p <br /> Signed X Title: Date: /4" Z, 1 8o <br /> (Draw Plot Plan on Reverse Side) <br /> i <br /> FO DEP TMENT SE ONLY <br /> PHASE I <br /> Application Accepted By /"``� _61 <br /> Date � Y <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date �_ $Q <br /> E - <br /> Fee i6 Due: ❑ ANNUALLY El PER UNIT I PER SITE ❑ EACH ❑ January 1 &Receivedanuary 31 ❑ July 1 Received By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUEREMIT ' <br /> BASE EXPLANATION ' CHECKED <br /> DATE DATE REMITTED 'l AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER .�,�= <br /> OTHER <br /> Received by - Date Receipt No. Permit No. ��-- Issuance Date A mailed Y- Delivered <br /> 01 E,HA <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/sERVICEs 1 <br /> 601 E. ZELTON-AVE.,P.O.Bp:2009 STOCKTON,-CA 95201- <br />