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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> fOR OFFICE USE: APPLICATION <br /> '(For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT f ' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance wi.t n n untyAr inane No. 1862 a rul pn regulations of the San J� min Lgc strict. <br /> Exact Site Address �S �! City/Town <br /> Owner`'s Name Vivo P", Phone <br /> Address t" al f I r. City <br /> Contractor's Name - 10 Mllt. 6Micehse# Business Phone i;__,_._ <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Ll__� I No ; <br /> TYPE OF WORK (CHECK): NEW WELL❑' " DEEPEN ❑ RECONDITION 13 DESTRUCTION[:]'--- ' <br /> WELL CHLORINATION.[] WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 0} <br /> REPLACEMENT❑ <br /> On A <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines �.. Pit Privy <br /> Sewage Disposal Field Cessprr��o,,,o,�ll/S�@1epage Pit Other <br /> k Property Line��Private Domestic Well-Wa- ublic Domestic Well <br /> INTENDED USE TYPE OF WELL f��l <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation / <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing / <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing <br /> IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL n S�Grf c ea InstaIle y: -.14 <br /> v[¢ <br /> PUMP INSTALLATION: Contractor155;�S/05 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done `. <br /> PUMP REPAIR. ❑ State Work Don <br /> DESTRUCTION OF WELL: Well Diameter pproximate Depth <br /> Describe Material and Procedure <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." - <br /> 5. �aV1Inspection prior to grouting and a final inspection <br /> Signed X Title: &IAWA <br /> dA ZA4 <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (� �� 11 _ <br /> Application Accepted By "� Date��` <br /> Additional Comments: <br /> Phase 11 Grout Inspection _—Phase III F'rial Inspection <br /> Inspection By CYC i C Date Inspection By Date <br /> r <br /> Fee Is Due:-❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 < <br /> REMIT <br /> BILLING _ REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS t <br /> PRORATION <br /> PLUS' P <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received byDate - Receipt No. Permit No, I uance Date _Mailed Delivered' - <br /> APPLICANT—RETURN ALL COPIES TO:—EhVIRONMENTAL HEALTH PERMIT/SERVICES � 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />