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x Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 0ICE USE: APPLICATION <br /> } (For Non-Transferable, Revocable, Suspendable)1 <br /> 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/orinstall 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 S "� , / f ( C1ty/Town <br /> Owner's Name 7hone ° <br /> �-, ,=�Jc A-- <br /> Address City <br /> Contractor's Name ' License#J-66 7W- 4 Business Phone �F <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_. L�s No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 9�— PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank / Sewer Lines_ .1 f/ Pit Privy <br /> Sewage Disposal Field 6101 <br /> Cesspool/S?epage Pit Other <br /> Property Line Z40 t_ Private Domestic Well_ Public Domestic Well <br /> i <br /> INTENDED USE TYPE OF WELL, j <br /> ❑ INDUSTRIAL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> 'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> I <br /> ❑-DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ZjAli fl <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 /> Ii <br /> F <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:A 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 wil ca11 for a Grout Insp on prior to gr uting and a final inspec 'on. <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> E ' <br />` FORD PARTME T USE ONLY 'I <br /> PHASE I ' <br /> Application Accepted By � Q^Z Date e o M <br /> Additional Comments: <br /> 1 Phase III Final Inspection <br /> Il Phase II Grout Inspection <br /> Inspection By Date Inspection By r to <br /> ,c� � <br /> Fee Is Due: ❑'ANNUALLY ❑ PER UNIT ruPER SITE 11 EACH ❑ January 1 &Rec6ved By January 31 ❑ July 1 &Received By July 31 <br /> REMIT i <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �t v <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> u <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No PYrmiI No. - lisualrice Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95.201 <br />