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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: ! APPLICATION <br /> CD pke(6 441 (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> f <br /> __-_ __. ( ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 Ordinance No. 1862 and the rules and regulations of the San Joa w Loc I Health Di Hct. <br /> Exact Site Address �C�11 @�'�- g __ City/Town - G <br /> Owner's Name L Phone <br /> Address �I; R-�� ��®hteQ�� City__ 1 �O <br /> Contractor's Namet 5o4-xse�mA 4 License# Z� Business Phone c G Y <br /> Contractor's Address ° Emergency Phone --- N <br /> G <br /> Is Certificate of Workman's Compensation Insurance on File W' SJLHD? Yes_X_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 59 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 Sed By: <br /> PUMP INSTALLATION: Contractor '^ q _ <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _. Approx+mate Depth <br /> Describe Material and Procedure _ <br /> 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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Insp cti n o to gr Ing and final inspection. <br /> Signed Itie: _— Date: <br /> (Draw Plot Ian on Reverse Side) <br /> F R RTMENT USE ONLY <br /> PHASEI DEP 7 <br /> Application Accepted By ICAP.7 Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By�� Date F Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 5 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT —_ <br /> FEE zi <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Is uance 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 />