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Applications Will Be Processed When Submitted Properly Completed Be SureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> 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 Joaq In County Ordi ante No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �7S ��� ' ec�� City/Town � j� k , . <br /> Owner's Name (2Phone JR,&q- a <br /> Address A cityIn, <br /> Contractor's Name License ii 3R3 Business Phone a ;? 9 - <br /> Contractoi Address �e _r�_ti IfR^-71a�T Emergency Phone ��- <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 /> DISTANCE TO NEAREST: Septic Tank 1 7� Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit __41S`O Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL r <br /> ❑ INDUSTRIAL ABLE TOOL Dia. of Well Excavation 1 c�- <br /> � r <br /> `DOMESTIC/PRIVATE t <br /> RILLED, Dia. of Well Casing <br /> [❑ DOMESTIC/PUBLIC `�—❑ DRIVEN w--- Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout = a& <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal,Installed By: t-x Co <br /> PUMP INSTALLATION: Contractor J C, I/,>"f)P, I I E <br /> Type of Pump :% . H.P. �} <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done I �; <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 cetiifies 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 sut;hymanner 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." <br /> I will call for a Grout Inspection pridnto grouting and a final inspection. <br /> Signed X I '` /A 13 4�A Title: _� ��'G/ / ��4�, Date: <br /> - (Draw Plot Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY <br /> ,._PHASE IF <br /> Application Accepted By L Date �3 <br /> Additional Comments: 1 <br /> .fiPhase 11 Grout Inspection - - '"" �"" - Phase III Final Inspection <br /> Inspection Byw. _ Date �� �3i {t Inspection By 72 . Date 1-2-1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BREMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Wermit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />