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ApplicationsWill BeProcessedWhen SubmittedProperlyCompleted. Be Sure To Sign The Application. . <br /> FOR OFFICE USE: �, ; APPLICATION -3 Irv- <br /> (For Non-Transferable, Revocable,Suspendable) <br /> K PUMP&WELL <br /> R 1 ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I WATER QUALITY <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 Joa uin County Ordinance No. 1862 and the rules and regulations of the SanJc J inmLocal Health District, <br /> Exact Site Address Ztp aQ City/Town <br /> Owner's Name Phone ( � <br /> Address d. .�_ ARMS A iGity <br /> Contractor's Name icense �-/Business Phone�. e 7 C] S <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on File With SJLHO? Yes 1>41 No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 0 <br /> WELL CHLORINATION ❑--�'1NELL,ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ # <br /> DISTANCE TO NEAREST: Septic Tank ZZ) Sewer Lines Pit Privy +' t <br /> Sewage Disposal Field ! Cesspool/Seepage Pit _,�Q_ Other '1 ? <br /> E Property Line I Private Domestic Well �� Public Domestic Well T tAa.,ce <br /> r <br /> INTENDED USE` € TYPE OF WELL r y <br /> ❑ INDUSTRIAL ' I <br /> ,�CABLEtTOOL Dia. of Well Excavation i <br /> DOMESTIC/PRIVATE, f ❑ DRILLED Dia. of Well Casing �] <br /> ❑ DOMESTIC/PUBLIC' "r ❑ DRIVEN Gauge of Casing a <br /> ❑ IRRIGATION #c ❑ GRAVEL PACK Depth of Grout Seal �� r <br /> ❑ CATHODIC PROTECTION' ❑ ROTARY Type of Grout „ dl <br /> ;❑ DISPOSAL .. ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL { ;~ Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor__ _ <br /> Type of Pump 's-AA H.P. <br /> `PUMP REPLACEMENT:4 r ` '❑ State Work Done f w' <br /> PUMP REPATR- ! ❑ State Work Done <br /> DESTRUCTION O�WE Well DiameterA_ <br /> ... pproximate Depth S� <br /> �D scribe Material and Procedure <br /> �- .� , Ger*-�- Gtir.�►�C -� �r / .c <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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 /> 4 <br /> I will call for <br /> a Gro t Inspection prior to grouting and a final inspection. Cj l <br /> Signed X Title: 4 _ Date: ]r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r <br /> Application Accepted By pat <br /> Addition I Comments: - <br /> �Qj� ` n �as II Grou Inspection Ph I Final In ction <br /> } Inspection ray Date Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE °'❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE '�s� * { <br /> LESS <br /> PRORATION - <br /> k <br /> PLUS } <br /> PENALTY <br /> f <br /> OTHER <br /> - OTHER - <br /> I <br /> Received by Date Receipt No P-?SoUermit No. Issuance Date Mailed- Delivered <br /> �' � <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 200.9 STOCKTON,CA 96201 <br />