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FOR OFFICE USE: APPLICATION <br /> Non-Transferable,Revodable, Suspendable) PUMP&WELL <br /> /7L <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/ohnstall thework herein described.This application is <br /> made in compliance with San Joaquin County Ordi ance No. 1862 and the rules"and re ulations of the San Joaquin Local Health District. <br /> Exact Site Address`" r�W& tilt/ `rFtla_ City/Town <br /> Owner'.s Name '-/C- A re. - Phone . <br /> Address City <br /> Contractor's Name CWWWk. i:License if"1g3�33-�Busine' s:Phone 'Y <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HD? Yes fie No <br /> TYPE-OF WORk`(CHECK): - -NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> .rl <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> `s <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal.Field. Cesspool/Seepage Pit ether <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 'Other Information <br /> GEOPHYSICAL,_ Surface Seal lnstal.led By: . <br /> PUMP INSTALLATION: Contractor02 <br /> Type of Pump.. mar A 0"A-W'Q,,ltk. H.P. <br /> PUMP.REPLACEMENT:.. 0 .State Work Done <br /> PUMP RE *111: State Work,Done <br /> DESTRUCTION OF WELL: W611 Diameter Xpproximate Depth <br /> Describe Material and Procedure <br /> a_z <br /> 1 hereby certify that 1-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 ofthe 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 /> 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 I call fora Grout Inspect' p :gro g and final inspection. <br /> Signed X. itle: �r� Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / D� <br /> Application Accepted By <br /> �- I _� --��' Date <br /> Additional Comments: - 3 <br /> Phase)l Grout Inspection IIIF� <br /> ,/'nal Inspection <br /> Inspection By �� Date lr ___ I"nspection Syv�` Date S✓��! <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE Q EACH ❑ January 1 &Received By January 31 - ❑ July 1&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE - - <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER } <br /> r <br /> OTHER <br /> Received by Date Receipt No. Permit No. .Iss ante 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 />