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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) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora 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 SaA-,U*quin Local Health District. <br /> Exact Site Address P-1(-3T F-0 City/Town n-C A—­-O <br /> Owner's Name r l) i y-0 Phone c�.� --7rTr� lC�-'s—d7 Sn <br /> Address t C7-� TLC> City <br /> Contractor's Name C-O License# Business Phorie 524 ¢,"a <br /> Contractor's Address t Emergency Phone _S70--'n t C7— <br /> Is <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 4� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br />'i Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE POOL 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 Sea] <br /> ❑ 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 e.— H.P. S /� <br /> PUMP REPLACEMENT: �`r�f' State Work Done I "1"/F� c / 17 1 _._�h 2 <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 /> 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 forwhich this <br /> per 't is is ed, I shall em loy persons subject to workman's compensation laws of California." <br /> 1ill 1I f r Grout Inspe 'on prior to grouting and a final inspection. <br /> Signed X Title: _ _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> i Date <br /> Application Accepted By - �. <br /> Additional Comments: _ <br /> Ph I Grout Inspection P e I Final I ection r� <br /> Inspection By Date Inspection B ate /—/-0 12 - <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br />] BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> ry FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �} j <br /> Received by Date Receipt No, Permit No Issuartce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICE§ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> f.F <br />