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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i (COMPLETE IN TRIPLICATE) WATER QUALITY Z-67f <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 County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address A�/,7 [RJ r 7?4FDO V D 0 City/Town T ' <br /> Owner's Name IDA OMO Phone <br /> Address 9 S 7— __. City�l� <br /> Contractor's Name FMFl ES A5f 4L(=—LB I License#33 ,7l Business Phone`.20th <br /> i <br /> Contractor's Address P,,G r �,�' l�fc.eS c5' Emergency Phone , <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION I& PUMP REPAIR❑ T <br /> REPLACEMENT❑ <br /> E � <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy [1� <br /> Cesspool/Seepage Pit <br /> Sewage DFspp�SaEl'Fiefd, � Other_ <br /> Property Line 06 Private.Domestic Well Public Domestic ,Well <br /> INTENDED USE 13 TXf3E10F WI=LD f gam" ` 3 <br /> ❑ INDUSTRIAL El CABLE TOOL Dia, of Well Excavation <br /> ,DOMESTIC/PRIVATE E] DRILLED Dia. of Well Casing +» <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of}a4g <br /> 11 IRRIGATION E] GRAVEL. PACK DepthFofW -r�lt Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of I rout <br /> 11 DISPOSAL C1 OTHER Other Info\rmation <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor cTRY_ <br /> Type of Pump it H.P. <br /> PUMP REPLACEMENT:'"' ❑ State Work Done <br /> PUMP REPAIR: C1 ❑ State Work Done <br /> DESTRUCTION OF WEL'L:N Well Diameter Approximate Depth <br /> Describe Materia!and Procedure <br /> d � <br /> 1 herebcertify that have prepared this application and that the work will!be done in accordance with San Joaquin County <br /> ordinarices,,state Iwo s, and rules and regulations of the San Joaquin Local Health District. ; <br /> Homeowner or licen led agent's signature certifies the following:"I certify tha�in the performance of the work for which this permit l <br /> is isst5ed*`I•shall not mploy any person in such manner as to become subjAt to work-man's compensation laws of Califorrila"-»-,. <br /> Contractor's hiring orFsub-contracting signature certifies the following:"I certify that in the performance4f the work forwhich this > <br /> permit is'issued, I sh 11 employ persons subject to workman'spensation laws f(q liffornia.''dt°k ),�A�5\ I <br /> I will:. a Grout Inspection prior to grouting and a,tinal inspection. <br /> Signed Title: Date: <br /> (Draw Plot Plan on Reverse Side) f <br /> ( FOR DEPARTMENT USE ONLY j <br /> PHASE 11 <br /> r <br /> Application Accepted By- Date <br /> Additional Comments: <br /> Phad a 11 Grout Inspection /-,Phase III Final Inspection <br /> Inspection By ! Date Inspection By Date 7 I <br /> 6 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT N'PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE ExPLANAT N AMOUNT DUE CHECKEp <br /> > DATE DATE REMITTED AMOUNT <br /> FEE f d <br /> LESS { <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 c- �! `? <br /> IL _,-01Received by 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,CA95201 <br />