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FOR OFFICE USE: APPLICATION <br /> r or Non-Transferable, Revocable,Suspendable)` PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALIFY- # <br /> T 1 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San/Joaquin County Ordinan a No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address- 1 � /�� _ q q City/Town <br /> Owner's Name idi,iiiownt4o�aex Phone ` <br /> Address d -City <br /> Contractor's Name �Elw-� �,,! License# Z�6, Business Phone <br /> Contractor's Address I'' Emergency Phone ( 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I No <br /> TYPE OF WORK (CHECK): NEW WE RECONDITION 13 DESTRUCTION <br /> WELL CHLORINATION ❑ W L ABANDONMENT OTHER ❑ PUMP INSTALLATION 11PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines F 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 <br /> d ; <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Welt Casing <br /> II BLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal . <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done •-- <br /> PUMP EPAIR: ❑ State Work Done (� <br /> r-IDESTRUCTION OF WELL: Well Diameter Approximate Depth C <br /> Describe Mate r'al and Procedure ) <br /> c `�' <br /> I herebl 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 /> 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 taws.of California. <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which chis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for Grout spection prior tvbrouting and a final inspectia . <br /> Signed X Title: r L Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 1 <br /> Application Accepted B _ Date �'v <br /> Additional Comments: 71�7t T1 <br /> ) 7 <br /> Phase 11 Grout Inspection ase Final Inspection <br /> Inspection By Inspection By Q Date / � � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUREMIT <br /> E CHECKED <br /> AMOUNT <br /> FEE C Q O a_ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - 4 <br /> OTHER Yi k <br /> OTHER <br /> Received by Date Receipt No. Permit No. -Issu me D to Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />