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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i FOR•JFFICE USE: APPLICATIONcy�. r <br /> (For Non-Transferable,Revocable,Suspendable) L a <br /> - PUMP LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPL:rE E 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 ounty mance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> , �. <br /> Exact Site Address_ ��►f� )��BJ� City/Town ���C j[ T�(y cam/ <br /> p Owner's Name �'�► + t r 1 1 c,i-3�} !dr, Phone f o[ rL-5 <br /> k Address 9� R &g�A City ``'45 C-K -t b kt,-' <br /> 6NN 1y �' 1/e'S`- <br /> Contractor's Name J�t/�S t��OS License# Business Phone �, <br /> Contractor's Address Emergency Phone ��''� ,L/zf�� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL,. DEEPEN ❑� RECONDITION-E] DESTRUCTION❑ <br /> ` WELL CHLORINATION E] WELL ABANDONMENT13 OTHER-❑, PUMP INSTALLATION ❑ PUMP REPAIRC� <br /> REPLACEMENT❑ _ / __ <br /> DISTANCE TO NEAREST: Septic Tank O Sewer Lines Pit Privy <br /> Sewage Disposal Field '1`"' Cesspool/Seepage Pit '"�' Other —r <br /> Property Line Private Domestic Well PublicDomestic Well <br /> INTENDED USE TYPE OF WELL 3 f IJ <br /> I ❑ INDUSTRIAL `< ❑ CABLE TOOL Di`a. of WeNExcavation <br /> lit <br /> *141 <br /> <DOMESTIC/PRIVATES *� ej. ❑ DRILLED . t` Dia. of Well,Casing � <br /> 4 ElDOMESTIC/PU'BLIC 1 C1 DRIVEN ; ? p Gauge of C sing <br /> ❑ IRRIGATION ` X(GRAVEL PACK ` Dept Grout-Seal- <br /> ❑-CATHODIC PROTECTION ROTARY Type of Grout 19e <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> © GEOPHYSICAL . Surface Seal-Installed By: <br /> PUMP INSTALLATION; Contractor 9 <br /> Type of Pump,- ^—� �` H.P. <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 <br /> ?a. 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-contractingsignaturecertifies 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 /> r <br /> I will call fora out>Inspec on prior to grouti g and a-final-insp- tion:-� <br /> Signed X Title: Date: O '" <br /> -Z (Draw Plot Plan on Reverse Side) <br /> FO DEPART ENT USE ONLY <br /> PHASE 1 <br /> 1 Application Accepted By Date —7 r <br /> Additional Comments: <br /> d Phas II'GroW InspectionPhas III Final Inspection <br /> Inspection By Date O ` r Inspection By Date <br /> $— kv`lot <br /> i - Fee Is Due:-❑ ANNUALLY 0 PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE ' CHECKED <br /> DATE TE REMITTED AMOUNT <br /> ` FEE or— <br /> t LESS <br /> PRORATION <br /> PLUS <br /> • PENALTY va <br /> OTHER <br /> OTHER <br /> 71 <br /> 1 Received by (Daid Receipt No. Permit No. lisuarfce Date Mailed Delivered <br /> E APPLICANT--RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH-PERMIT/SERVICES - 1601€.HAZELTON AVE.,.P.O.Box 20U9 STOCKTON,CA 95201 <br />