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ApplicationsWill Be Processed When Submitted Properly Completed..Be Sure To Sign The Application. <br /> FOR OFFICE USE: ] APPLICATION / <br /> *' •,, _a f (For Non-Transferable, Revocable,Suspendable) Via¢ <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) 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 Joaquin Cot(n r ance_No. 186 a d the rules and regulations of the San Joa in ca Health District. <br /> Exact Site Address City/Town S <br /> 1 �7 <br /> Owner's Name 4 f j �1 �- i ` tc I r Phone 9� / <br /> Address I ��t< •e-v-4 Lok City-_6 oC •C e o t� <br /> Contractor's Name J j EG License#1 S39'77 Business Phone <br /> i Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL E] DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ ' PUMP INSTALLATION PUMP REPAIR❑ rr '',, f <br /> REPLACEMENT❑ _ ll� <br /> 1 k <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �1 <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 /> Dk-b0ME-&T419/<P-R4-VATE 11 DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC 0 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 /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ,.) n� <br /> Type of Pump H P <br /> t PUMP REPLACEMENT: ❑ State Work Done u <br /> PUMP REPAIR: ❑ State Work Done A� <br /> DESTRUCTION OF WELL: . IWell Diameter_,� <br /> - _ - s <br /> Approximate Depth ��UO <br /> Describe Material and Procedure -� <br /> W <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this permit 1 <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 1 <br /> permit is issued, I shall employ } <br /> p y persons subject to workman's compensation laws of California." rt <br /> I will call forarouttion prior to grouting and a final inspection. <br /> Signed X - <br /> Title: Date: <br /> (Draw Plot Plan on Reverse Side) L i <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE <br /> Application Accepted By — Date <br /> r <br /> Additional Comments:. <br /> Pf1a °^ ha II Final Inspection I <br /> Inspection By 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 .f <br /> BASE EXPLANATION A <br /> DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT ' <br /> FEE <br /> LESS ( r <br /> PRORATION - <br /> PLUS <br /> PENALTY t <br /> OTHER <br /> OTHER r 1 - <br /> 4 UO 7J O <br /> d yy Dat Receipt No. Permit No- Issuance Date Mailed DeliveredLR'e..',.',,v,. <br /> ICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON,CA 95201 <br />