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r1,PpecanonswillBeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFIC:USE: <br /> LS`+ PMATION <br /> —'",— (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> PUMP&WELL f <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S <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 No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address &36 Sf 'S City/Town -� <br /> Owner's Name + Phone <br /> Address + City <br /> Contractor's Name +. .✓ License#pZW—­0Business Phone__- .a.�a�,7 <br /> Contractor's Address .2bo Emergency Phone +-sti ff`. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <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 /> 4 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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Q�+ <br /> GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> .3 <br /> Type of Pump H.P. C!1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done d° Gt/i:1LP <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth � <br /> Describe Material and Procedure <br /> C <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 /> 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 /> I will c I for a Grou spe 'on prior to grouting and a final inspection. <br /> :t Signed X <br /> Title: Date: <br /> (Draw Plot Plan on everse Side) <br /> FOR EPARTME T USE ONLY <br /> PHASE 1 n <br /> Application Accepted ByDate !a r79 <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph se III Final Inspection <br /> Inspection By Date Inspection By Date — �d <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE � �/ r AMOUNT <br /> T <br /> LESS VVJJ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receiver!by Date Receipt No. Permit Ne. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 95201 <br /> -- rwA <br />