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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OF6ICE USE: APPLICATION s f <br /> , 4 tw� (For Non-Transferable, Revocable,Suspendable) <br /> 4r"te ��,MP 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 County Ordin nce No. 1862 and the rules and regulations of the San Joaquiry Local a Ith District. j <br /> Exact Site Address_��VX* ,� / City/Town �� <br /> Owner's Name iP7 /�� Phone <br /> Address /t� city ^- <br /> 74r 7 <br /> Contractor's Name � . 7License# �j Business Phone <br /> Contractor's Address &A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With LHD? Yes _ No n, <br /> TYPE OF WORK-(CHECK): NEW WELL El DEEPEN 11 RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer.Lines R Pit Privy ) <br /> Sewage Disposal Field Cesspool/Seepage Pit Other } <br /> Property Line Private Domestic Well F Public Domestic Well 4 <br /> _ k <br /> INTENDED USE TYPE OF WELL <br /> ,❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> Ips,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 /> ❑ GEOPHYSICAL ` . Surface eal Installed By i� <br /> PUMP INSTALLATION: Contractor �rJrG <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State ork Done ` °" '�`��' <br /> W ' k <br /> PUMP REPAIR: 0 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter—' Approximate Depth <br /> Describe Material and Procedure ) <br /> 4 <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. F } <br /> Home owner or licensed agent's signature-certifies the following:"I certify that in the performance of the work for which this permit i <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 certity that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Al 'll call for a Grout Inspection ri g uti an final inspection. <br /> Signed e: Date: / <br /> (Draw Plot Ian on Reverse Side} f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 OpS� Q� <br /> Application Accepted By-Aft <br /> DateV <br /> Additional Comments: <br /> Phase II Grout Inspection P as III Fjial Inspection ` js, <br /> Inspection By 1-T-ice— Date inspection By t Date a <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 $ AMOUNT DUE CHECKED <br /> SASE EXPLANATION DATE DATE REMITTED s, <br /> AMOUNT <br /> FEE CV�t7 <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. - Permit No, Issuance Date Mailed Delivered v <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />