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r.ppvv..•,v.•v ..•••uc. •..•.vvvs.• .. ..:..v.v...•uv.. •vpc•.� vv...p.c•c... va vu•o v.anon enc rrF+r.wa•.w.. <br /> FOR OFFICE USE: APPLICATION <br /> r(For Non-Transferable, Revocable,Suspendabll <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)� � ^ice WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work h i' es ed I Ion is <br /> made in compliance with San J aquin County Ordinance No. 1862 and the rules and regulations of the San Joaq I� I�eaitt5 p <br /> Exact Site Address . ��- S, 00_ ! City/Town IGi EEE��� {� ii <br /> Owner's Name Phone <br /> Address m©• City <br /> Contractor's Name License#1419,7 3 Bus,iness Phone 3 6 —S <br /> Contractor's Address LT <br /> Emergency Phone (-(a^9e _) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER-❑ PUMP INSTALLATION 0-" PUMP REPAIR❑ <br /> REPLACEMENT❑ O <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 1V <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 pia. of Well Casing <br /> 11-DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> X IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal II stalled By: <br /> PUMP INSTALLATION: Contractor—_ _��C�r-�-��a� <br /> Type of Pump / H.P. �© <br /> H <br /> PUMP REPLACEMENT: P. State Work Done <br /> PUMP REPAIR: ❑'State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> --Describe-Material and-Procedure- - _._._..... <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:1 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:1 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 r at r a Grout pection.p ' r to grouting and a final Inspection. _ <br /> Signed X �T Title: Date: <br /> (Draw Plot Plan on ReversAide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date 1 <br /> Additional Comments: <br /> Phase fl Grout Inspection PhaseIII Fi al�I spection <br /> Inspection By lf] Date Inspection By atey Iry <br /> Fee IS Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Receive y January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE- CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS' <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �Is <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 />