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Applications Will Be Processed When Submitted Properly Completed. BeSureTo Sign TheApplication. <br /> fOR OFFICE USE: JJ APPLICATION <br /> Com (For Non-Transferable-, Revocable, Suspendable) I <br /> / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ('l21`;,c ,./� cd�S C'�- WATER QUALITY `0 t —0-7.D --eo <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 San Joaquin Local Health District. <br /> Exact Site Address ip4l,C Lam.f Ac Sfi11W,_r_leu City/Town <br /> Owner's Name O ; d Phone T _— <br /> Address gct'_ a- /� City.____C:�' <br /> Contractor's Name License# —Business Phone I _7_7k7_4 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S LHD? Yes_ __.� No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ECONDITION❑ DESTRUCTION❑ <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 /> ` <br /> Property Line Private Domestic Well Public Domestic Well <br /> p Y <br /> INTENDED USE TYPE OF WELL 1 <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation_ - ^�,• <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 10 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout (� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By'. <br /> PUMP INSTALLATION: Contractor 4 0 <br /> Type of Pump ` H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP 86411 4R: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth h <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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection rior 10 rputtrnMnd a lippil inspection. <br /> _/V�, <br /> Signed y e: Date: <br /> (Draw Plot P an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By �471/ <br /> ZeDate —` ! / 9 <br /> Additional Comments: r , <br /> Phase 11 Grout Inspection Phas III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT IFPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE JEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -7- <br /> -7n- <br /> `r7n- i3:�ls - <br /> Received by Date Receipt No. Permit No. I s s u ance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />