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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) <br /> PUMP&WECf. <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ���r1E�e1d�E' / 7 WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This applicatj.on is <br /> made in compliance with San Jo q�uriin County Ordin nce No.1862 and the rules and rglations off the an Jo quin L cal Healt Distri�(t. <br /> Exact Sit{Address / L(/�f7i"/l�2/YC�4?e Q�/�/!�l/1�/' E � i 7di Rc� L f E`Y i�J4: <br /> - <br /> Owner's Name . Aoh (196e, Phone <br /> Address / -�6 _ � City <br /> Contractor's Name �lt�f'ilC d�1 a,2) -A6e,�QLicense# oL:2?e9,?/.3 Business Phone <br /> Contractor's Address "dm! 0/ a7Z1 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No l� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 44} <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ v� <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank AV Sewer Lines Pit Privy <br /> Sewage Disposal Field /W_ Cesspool/Seepage Pit Other F i <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 1v❑f DRIVEN Gauge of Casing LtJ <br /> ❑ IRRIGATION ,+o+ GRAVEL PACK Depth of Grout Seal 160 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 f <br /> Describe Material and Procedure n <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 thework forwhich 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." 1 <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 all for a Grout I specti prior to groulin and a final inspection. <br /> Signed X Title: Date: °��S �� <br /> (Draw POV.Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE I j> <br /> Application Accepted By Date U �. <br /> Additional Comments: <br /> P se II rout Inspection Phase III Final Inspection <br /> Inspection By ' Date �! Inspection By A/ Date f <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rn <br /> Received by date Receipt No, Permit No. Issuance Date .Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P:O.Box 2009 STOCKTON,CA 95201 _ <br /> k - <br />