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Applications Will BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. ! <br /> FOR OFFICE USE: APPLICATIONQCj ! <br /> (For Non-Transferable, Revocable, Suspendable) � LP <br /> PUM WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or installthe work herein described.This application is <br /> made in compliance with San Joaquin County Or ' neo.1862 nd the rules and regulations of the San Joa in Lo al Health District. <br /> Exact Site Address ��✓ bty/Town 6 <br /> r <br /> Owner's Name K ok Phone <br /> Address _ City } <br /> Contractor's Name vYu rv• License# 90Y Business Phone 75 1— ivy y <br /> 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❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �`� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR E3 [ <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 /> �} <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing { <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Z <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sace Seal Installed By: <br /> PUMP INSTALLATION: Contractor S Vrv. <br /> ILI <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 <br /> Describe Material and Procedure l <br /> 1 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. `l <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit 5 <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 w' II for a Grout 5pection nor to grouting and a final inspection. <br /> Signed X. Z27 Title: Date: 36Z S 79 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By '^^ Date 1 7� <br /> Additional Comments: <br /> i <br /> Phase II Grout Inspection se II Final lnsp cfion <br /> Pha <br /> Inspection By Date Inspection By ate <br /> Fee IS Dile: ❑ ANNUALLY ❑ PER UNIT ClPER SITE ElEACH ❑ January 1 8 Received By January 31 © July 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORAT4ON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br />' Received by Date Receipt Nb. Permit No. Issuance Date Mailed Delivered ,.- <br /> 1 __ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201_r <br />