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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> va t = boy j��. (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a 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 Loca(Health District. <br /> Exact Site Address ! ?J A) City/Town <br /> Owner's Name m U �4 m Phone <br /> Address / A/ City <br /> Contractor's NameLicense#_r'rC3-7'241'Business Phone" <br /> • <br /> Contractor's Address /tack Emergency Phone, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X _ No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] a1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR RL <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field -Cesspool/Seepage Pit Other__ <br /> Property Line Private Domestic Well 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 /> © DOMESTIC/PUBLIC L1 DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK..- Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY 3 Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ • <br /> Type of Pump_ 2o,6,w&nLAAAa, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 99 State Work Done ,y <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County l <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 1 <br /> r 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 s <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I Ill tail for a Grout Ins ectio rid-r to routing and a final inspection. <br /> Signed _ Title: _ 641r <br /> - Date: <br /> (Draw P qt Ian on Reverse Side) i <br /> - - I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By bate a"k—"0" � <br /> Additional Comments: ! <br /> ?Phase II Grout Inspection ° <br /> Int Final Inspection <br /> Inspection By Date Inspection y [ Date ` <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT C1PER SITE I❑ EACH ElJanuary 1 &Received By January 31 '❑ July 1 &Received By July 31 ` <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED r <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION i <br /> PLUS , <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> ,Received by Date Receipt No. Permit No - _ I wanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201— ..d <br />