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r�. & Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> s PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit-to construct and/or install the work herein described.This application is <br /> �s <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin.vocali Health District. <br /> ' Exact Site Address� 5�{��� �S1Ud. �mr_e_!_ Oi^ 1, TI'VA .0 - City/Town <br /> Owner's Name f G Phone 1-,e(o LJ q Z " 06 <br /> Address S. 7rM.-I, City <br /> Contractor's Name. '44-l'}imi In etS. License# 29Q(11- Business Phone— <br /> Contractor's Address J�� �fy1C7G�f�f� Emergency Phone 7/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLH_W..� Yes�� No <br /> TYPE OF WORK (CHECK): r NEW WELLVI DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT D OTHER 0 PUMP,'INSTALLATION ❑ PUMP REPAIR <br /> 7 REPLACEMENT❑ } <br /> ► DISTANCE TO NEAREST: Septic Tank _ �00 Sewer Lines 1-+ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well 'Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> t ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - <br /> �` DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 61 �P!/ r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN r Gauge of Casing <br /> ❑ IRRIGATION ya GRAVEL PACK Depth of Grout Seal <br /> R ❑ CATHODIC PROTECTION ROTARY Type of Grout f1 <br /> ❑ DISPOSAL ❑ OTHER s Other Information <br /> ❑ GEOPHYSICAL b Surface Seal Installed By:- p <br /> i , <br /> PUMP INSTALLATION:' Contractor _ <br /> Type of Pump H.P. .-• <br /> PUMP REPLACEMENT? r❑ State Work Done <br /> PUMP REPAIR: ! r❑ State Work Done <br /> DESTRUCTION-OF-WELL:,*. - Well-Diarrleter_, - `6` _- --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 a <br /> ordinances,state laws, and rues and regulations of the San Joaquin Local Health District. <br /> Homeowner or•licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit Q- <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 <br /> l permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call forGrout I pection prior to grouting and a-#final inspectlo - <br /> Signed X � I •� � � �- � _ Date: <br /> _, <br /> (Draw Plot Plan on Reverse Side) a '^ <br /> 7` FOR DEPARTMENT USE'ONLY <br /> PHASE I ,F - <br /> Application Accepted-By — -- - - - — Date <br /> Additional Comments: <br /> A <br /> ase l Yt Inspection PhaseII nspection <br /> Inspection By Date�J 0 Inspection By Date <br /> I <br /> F1 <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 /> .BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> k I DATE DATE REMETTED AMOUNT <br /> f <br /> FEE <br /> LESS' <br /> PRORATION <br /> PLUS <br /> ' PENALTY ¢ <br /> OTHER t <br /> + OTHER <br /> Received by °` Date -- Receipt No. - Permit No. - Issuance Date Mailed -Delivered <br /> �. APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 .STOCKTON,CA 95201 <br />