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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR-OFFICE USE. APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) �7f�0 _ S,cr��Q, WATER QUALITY 6�5.- ICO 0.- O,? <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 o. 1862 and.the les and gulations of the San Joaquin Lo I Health District. <br /> Exact Site Address ity/Town -n(�l _� _ <br /> Owner's Name Phone Ck c� <br /> Address City <br /> Contractor's Name License# Business Phone 3 4 q-a 7?9 <br /> Contractor's Address Emergency Phone �C.,°+�R�• _ —� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 74Z.- No <br /> TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION- PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1?�),o ° Sewer Lines Pit Privy _ <br /> Sewage,Disposal Field 'Cesspool/Seepage Pit Other + <br /> t Property Linea" Private Domestic Well Public Domestic Well _ <br /> INTENDED USE TYPE OF WELL <br /> r. <br /> ❑ INDUSTRIAL 3E-CABLE TOOL _ _Dia. of.Well.Excavation �a _ <br /> DOMESTIC/PRIVATE -ED Dia. of Well Casing C� °1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN .Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ° <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout. 0cUd <br /> ❑ DISPOSAL ❑ OTHER Other Information'i1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 4,2_0A, A <br /> PUMP INSTALLATION: Contractor <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 <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 for which this 4 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> �q <br /> 1 will all for a Grout Inspection prid'tto grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 1� <br /> PHASE I <br /> Application Accepted By a :+ T � � � ry� � �� Date <br /> Additional Comments: <br /> hase 11 Grout Inspection Phase III Final Innspection <br /> Inspection By_ i Tr Da + <br /> �� <br /> Inspection By , l 7�-�w�Ce� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ 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 DATE REMITTED AMOUNT " <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> L43 Llll�� <br /> Received by Date Receipt No Permit No. ' I <br /> nc� a pate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 f <br />