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s. Applications Will Be Processed When Submitted Properly Comp li T"Si��1 TYIepliaaI �. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Sus <br /> R PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT LQCpt <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN ,]OAQuiN-,vacIl <br /> r Application is hereby madeto theSan Joaquin Local Health Districtfora permit to construct and/or it l� k'Fierein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San. oaquiLL�n cal Health District. <br /> _/V <br /> r Exact Site Address /�+ � Z, l /� AD City/Town /pQ�Y <br /> i <br /> Owner's Name Phone <br /> Address City a c <br /> Contractor's Name S f 10A,C License# Business Phone Jr9l� �yJ <br /> Contractor's Address r 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 u DESTRUCTION❑ p�} <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 /> r INTENDED USE: TYPE OF WELL <br /> f ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well e=xcavation <br /> DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 4 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> II ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> © DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �~ <br /> PUMP REPLACEMENT: State Work Done ,C70/V7 gl hYL-X/ <br /> PUMP REPAIR. ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -� <br /> Describe Material and Procedure <br /> fI 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." Z1 <br /> I will C r a G o t Ins tion pr i to gr_QNjting and a final inspection. <br /> Signed X Title: _I <br /> Date. <br /> F_ (Draw Plot Plan on Reverse Side) <br /> -y <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By �� Date _� g 7/k <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> 7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> ,�q� _ AMOUNT <br /> FEE �7P <br /> I <br /> LESS <br /> PRORAT*N <br /> PLUS <br /> PENALTY 7 <br /> OTHER 3 <br /> OTHER <br /> Received by Date Receipt No. Permit No Issulance Datre Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />