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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> �. :00 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT -r . � <br /> (COMPLETEA K-TRI PLI CATE) WATER QUALITY <br /> Application is he`,by madeto the San Joaquin Local Health District fora permit to constructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co u tCit /Town <br /> y rdin ce No. 1 62 and the rules and regulations of the San JoaquinLocalHealth District. <br /> it S <br /> Exact Site Address <br /> J / Y <br /> Owner's Name �Je�1+s���y r[e n �£ _J Phane =k � n� <br /> Address _/_0 8 f�' _C Cyto e_ c,t 1�, City .5iFoe-A jo .r J :5: <br /> Contractor's NameLicense#;Z?, Business Phone <br /> Contractor's Address SO13 S VAI� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes— <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMt=NT❑ 1I <br /> DISTANCE TO NEAREST: Septic Tank o Sewer Lines Pit Privy <br /> Sewage Disposal Fyeld .�C9 t Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well�S..L7 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 /> ESTIC/PUBLIC ❑ DRIVEN Gauge of Casing R l <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 1A V45 <br /> ❑ CATHODIC PROTECTION KROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information p <br /> ❑ GEOPHYSICAL Surface Seal Installed By: a1LI &t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. I <br /> PUMP REPLACEMENT: ❑ State Work Done <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 U) <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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall empl y <br /> y persons subject to workman's compensation laws of California." <br /> Iwill call f a ut I p tion prior to grouting and a final inspection: <br /> Signed Title: *OAA.,u _ Date: <br /> (Draw Plot Plan on Rev a Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �/� /C <br /> Application Accepted By [/ Date <br /> Additional Comments: <br /> Phase 11 Grout nspection Phase III Final Inspection <br /> Inspection By 4�7 Date l Inspection By Dale <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE L4�� L7a <br /> LESS <br /> PRORATION <br /> PLUS /L 7 <br /> PENALTYAt <br /> OTHER <br /> OTHER <br /> U3940 8� -? <br /> Received by Date Receipt No. Permit No I suan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 20119 STOCKTON,CA 9520 <br />