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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATIONr <br /> p (For Non-Transferable, Revocable, Suspehdable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY, � : 4 -,f �a,, •-.. <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 compliancewith San Joaquin.County Ordinance No. 1862 and the rules and regulations of the San Joaquin Llacal Health District. <br /> Exact Site Address _ ✓ City/Town <br /> Owner's Nam M ' r Phone U <br /> Address g City V I <br /> Contractor's Namese4kF License# a Business Phone ' r <br /> Contractors Address ' ' ' Emergency Phone - ' GQ A <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No�� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO�FIs <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> I <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 TYPE OF WELL _ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL_ Dia. of Well Excavation F <br /> r <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ Dt5MESTIC/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 Seal Installed By: <br /> PUMP INSTALLATION. Contractor <br /> Type of PumpH.P. (� <br /> PUMP REPLACEMENT: r ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter I I A roxlimmate Depth <br /> Describe Maten an ocedure Q 4 I Y — � <br /> !I 1r �2r } r <br /> 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subjectrto workman's compensation laws of California." <br /> a <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work fo'r which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c II f r aGrrout Inspection priortogrouting and a final Inspection. <br /> Signed xl ` 7416 "✓tel Title: Date:,_L/_, <br /> `J (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY J <br /> PHASE I <br /> Application Accepted By Cr e-A <br /> Additional Comments: _ <br /> Phase 11 Grout Inspection Pha Itl Final Inspection <br /> Inspection By Date Inspection By Date �IQ�T9Z— <br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1A Received By January 31 ❑ July 1 &Received By July 31 l <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I <br /> FEE <br /> LESS' <br /> PRORATION <br /> PLUS <br /> PENALTY, <br /> OTHER - -� <br /> r h .. - <br /> OTHER <br /> Received by I Date Receipt No. - _ Permit No Issuance Date Mailed' DelWer ,t <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE-,P.O.Box 2009 STOCKTON,CA 95201 <br /> y r <br />