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M FOR OFFICE USE: / APPLICATION <br /> 1IDA�X0 (--�'ar Non-Transferable, Revocable, Suspendable <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein TI i LJ s <br /> j made in compliance with San Joa u' Coun`ty�rdi`nce No. 1862 and th le and regulations of the San Joaqui Loc al Isl ' t, llJl <br /> Exact Site Address 6 '� ' ` City/Town <br /> Owner's Name d Qhs !V I^t 1P.4i Phone <br /> j Address tlst' 'a^✓.- _ City <br /> t Contractor's Named License#_.lusiness Phone y �] a �1 <br /> Contractor's Address 6 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN 11 RECONDITION <br /> C I DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS a <br /> REPLACEMENT❑ <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 1 <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 Surfa Seal Install y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t.L I H.P. <br /> PUMP REPLACEMENT, State Work Done <br /> PUMP REPAIR: 96 State Work Done -0/4Z 4.6,ft-wro <br /> DESTRUCTION OF WELL: Well Diameter pproxim a Depth <br /> Describe Material and Procedure <br /> l 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 /> 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 alto become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"I certify that in the performance of the work forwhich this <br /> permit is issued, f shall employ persons subject to workman's compensation laws of California." <br /> I will call for.a Grout Inspection n o gr ng d.a final inspection. <br /> Signed XSM e: <br /> Dale: <br /> (D aw Plot PI on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted ey 6r Date <br /> Additional Comments: <br /> i Phase II Grout h spection _. has6 a peclion <br />! Inspection By ate inspection By <br /> Fee 13 Due: ❑ ANNUALLY ° ❑ PER UNIT © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 g,Received By July al <br /> BILLING REMITTANCE $ REMIT <br /> i BASE EXPLANATION - AMOUNT DUE CHECKED <br /> I DATE DATE REMITTED AMOUNT <br /> FEE .; <br /> LESS <br /> PRORATION <br /> i PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> i <br /> _I__� ,i <br /> Received by D to Receipt No. Permit No I 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 />