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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />' FFOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br />` ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaqu�nLocal Health District forapermit toconstruct and/or instalIthe work,herein described.Th is application is <br /> made in compliance with San Jo quin County Ordinance No. 1882 nd lh rules and regulations of the San Jo�quin cal Health District. <br /> Exact Site Address y O -� City/Town !.!? i <br /> Owner's Name V 1r. t Phone <br /> Address W.cl City k n i <br /> Contractor's Name O. License# O Business Phone <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© F <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION f$ PUMP REPAIR-0 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank S Sewer Lines _1 Pit Privy <br /> Sewage Disposal Field: Cesspool/Seepage Pit Other w <br /> Property Line _0 =_Private Domestic Well_f o Public Domestic Well <br /> INTENDED USE - z TYPE OF WELL <br /> ❑ INDUSTRIAL "CABLEITOOC Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ADRILLED Dia- of Well Casing -f -- <br />' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 - <br /> ❑ IRRIGATION C1 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout �' `1 1 <br /> ❑ DISPOSAL-- ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r Surface Seal Installed By:- oma C, et. C. - s <br /> PUMP INSTALLATION: Contractor <br /> W ' <br />` Type of Pump H.P. ? r H <br /> PUMP REPLACEMENT: ❑ State Work Done - — - <br /> PUMP REPAIR:. _State Work Done. <br /> DESTRUCTION OF WELL: „ ,O Well Diameter Approximate Depth' <br /> _ __._ •Describe Material and Procedure <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 /> I; <br /> Homeowner or licensed'agent's signature certifies the following:"I certify that in the performance of the work 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." <br /> s 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 <br /> I wjll c8ft a Grout Insp n p r to gring and a final inspection. <br /> 1:^ Signed XffD Title: PCI U of t/ �L' �� Date: d <br /> - (Draw Plot Plan on Reverse Side) <br /> }. FOR DEPARTMENT USE ONLY <br /> PHASE I t . <br /> R Application Accepted By Date <br /> Additional Comments: a „ <br /> Phase 11 Grout Inspection Phase III Final Inspection ryryl <br /> Inspection By ey !% Date -P- Inspection By It I`LAXJ%�o Date ` O <br /> Y-Fee is-Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> w „d REMIT <br /> "EXPLANATION BILLING REMITTANCE ?'. $BASE DATE DATE REMITTED AMOUNTDUE CHECKED <br /> AMOUNT <br /> FEE <br /> y._ <br /> LESS -` <br /> PRORATION f! <br /> r PLUS r I _ v <br /> PENALTY - I � <br /> OTHER <br /> - OTHER <br /> z -27f <br /> Received by 'Date Receipt No - Permit No iss ance Oaie Mailed Delivered r - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE P.O.Box 2009- STOCKTON,CA 95201 da <br />