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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �� <br /> =rbR OFFICE USE: APPLICATION J` <br /> .` (For Non-Transferable, Revocable, Suspendable) �'T <br /> PUMP&WELL ) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) r WATER QUALITY <br /> { Application is hereby made to the San Joaq{in Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San JoaquinCountyOrdinance No. 1862 and the r les and regulations of the San Joaquin Local Health District. <br /> Exact Site Address G� T- DA0n [sl�At �' City/Town <br /> Owner's Name �J�3��1_1 �0] Phone <br /> Address 0A... - �4d3 S CF�a +City <br /> Contractor's Name c.ru5 A--100/oV License 4Z7ZZ2-Z0 Business Phone �LGG6-O $SGS <br /> Contractor's Address C3 gn I?!Fb j-4 s, Emergency Phone I;$35 19 95 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes eK No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONK <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> x <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 /> INTENDED USE t TYPE OF WELL f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 3 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED°-l Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 0 DRIVEN � Gauge of Casing <br /> ❑ IRRIGATIONF ❑ GRAVEUPACK Depth of Grout Seal <br /> C1 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> a <br /> ❑ DISPOSAL I ❑ OTHER .R Other Information <br /> ❑ GEOPHYSICAL I ,' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump 1—`� ' . c H.P. <br /> PUMP REPLACEMENT: i []'State Work Done, <br /> J <br /> PUMP REPAIR. t t ❑ State Work Done _. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mat erial and Procedure , tAl,T/ !�kk <br /> I hereby certify that I have prepared this application a d that the work will b done in accordance with San Joaquin County <br /> ordinances, state laws,'and rules and regulations of the San Joaquin Local Health District. <br /> +' Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> I 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 h" inge. <br /> or sub-contracting signature certifies the Iollowing:"I certify that in the performance of the work for which this <br /> irmit is iss I shall employ persons subject to workmari's compensation laws of California." <br /> i I call t a Grout Inspection prior to grouting and a final inspection. - <br /> Signed XTitle: Date: 10 &nl/7? <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEP FITMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II GrCH Inspection a III Fi 1 Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER U%T A PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> k BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> I FEE yj u <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> k ' <br /> OTHER <br /> Received'ay Date Receipt No. Permit No, Issuance Date - Mailed Delivered <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />