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cation!Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. � <br /> FOFOFFICE USE: APPLICATION 3�1i <br /> (For Non-Transferable, Revocable,Suspendable) [ <br /> PUMP&WELL <br /> A I' ENVIRONMETi'iAL HEALTH PERMIT <br /> 3 <br /> (COMPLETE IN TRIPLICATE) E WATER QUALITY r:� <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 Ib <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the ru esand r ulations of the San Joaquin Local Health District. <br /> /I - <br /> Exact Site Address _ .�S4�,r /✓ t .-) W - City/Town <br /> Owner's Name &J., Phone <br /> Address w ! ' City r -7 <br /> Contractor's Namel��✓ ora�F� Ilii, !*,License# _s"� a Business Phone7 � <br /> Contractor's Address l Emergency Phone ': C9 <br /> Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW',WELLII DEEPEN ❑ RECONDITION Cl DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ i- I <br /> l <br /> DISTANCE TO NEAREST: Septi ciTank rp ' Sewer Lines gp Pit Privy <br /> Sewage Disposal Field /��- Cesspool/Seepage Pit -_ Other <br /> Property Line 14 Private Domestic Well es ' Public Domestic Well ^ <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 �� <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of CasingC-- <br /> ❑ IRRIGATION Ij GRAVEL PACK Depth of Grout Seal ;5_� <br /> ❑ CATHODIC PROTECTION ® ROTARY Type of Grout F ' <br /> ❑ DISPOSAL ❑ OTHER Other Information_ �''/ .� <br /> ❑ GEOPHYSICAL Surface Seal Installed By: -C�lr,! /yw w tr- D4411,�r <br /> ~.: <br /> PUMP INSTALLATION: ; Contractor A <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I� ❑ State Work Dane <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: I Well Diameter Approximate Depth ` <br /> Describe Material and Procedure <br /> a <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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.' j' <br /> I will call for a Grout Inspection prior routing and a final inspection. <br /> Signed X - Title: <br /> t�� _ '� Date: <br /> I� (Draw Plot Plan on Reverse Side) <br /> FOIR DEPPRTMENTJJSE ONLY !� <br /> PHASE 1 <br /> Application Accepted By Date <br /> II <br /> Additional Comments: - <br /> Phase jl Grout Inspection P ase 111 Final Inspection _77 <br /> Inspection By r Date �6 Inspection Byi Date <br /> � 97r1L9 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT �8:PEfl SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 , <br /> REMIT <br /> f BILLING REMITTANCE $ <br /> BASE I! EXPLANATION AMOUNT DUE CHECKED <br /> EEp DATE DATE REMITTED AMOUNT <br /> I. <br /> FEE <br /> LESS i <br /> PRORATION : <br /> PLUS <br /> PENALTY !R <br /> OTHER I <br /> �i <br /> OTHER Ii 11 <br /> Received by Date. Receipt No Permit No. Issuance Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 '{ <br />