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C <br /> .P y Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. y <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) h <br /> — � PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT •0 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY i <br /> AppliEation is hereby made to the San Joaquin Local Health District fora permit to construct and;or install the work herein described.This application is <br /> made in compliance with San Joa uin County Ordi an No. 18 a the.rules and regulations of the San Joaquin Lpc I Health District. <br /> Exact Site Address_Z2 r d City/Town _ 6 <br /> OwnersName xQ <br /> tAJ4& 649JU X Phone <br /> Address City <br /> Contractor's Name cense#.�2-ZI/ Business Phone — <br /> Contractor's Address / Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No J <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank � _� Serer Lines �t� ( Pit Privy <br /> Sewage Disposal Field_/0,0 f Cesspool/Seepage Pit Other <br /> Property Line/t>if—Private Domestic Well - Public Domestic Well -- ----- <br /> INTENDED USE TYPE OF WELL /r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well ExcavationAl <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 4 <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION - GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION XrROTARY Type of Grout C S-a.,� `` ► <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ,,12,- e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter—. Approximate Depth <br /> Describe Material and Procedure <br /> _.I hereby certify that l have prepared this application and that the work will be done.in accordance with San Joaquin County ` ll <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 thework for which this permit I <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-contractin ignat.re certifies the following:"I certify that in the performance of the work for which this y 1 <br /> permit is issued, I hall mpioy per ns subject to workman's compensation laws of California." 11 <br /> I I for a ut pecti routing and a final inspection. i <br /> Signed X <br /> Title: Dale: 8 eo <br /> (Draw Plot Plan on Rever Side) <br /> FO DEPARTMENT USE ONL <br /> 1 I <br /> PHASE 1 0 <br /> Application Accepted By Date [l <br /> Additional Comments: y <br /> Phase 11-Grout t Inspection Phase 111 Final Inspection <br /> Inspection By <br /> Date, '7—�� o Inspection By_ Date <br /> _- - _ <br /> f <br /> Fee IS OUB:ElANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &!Received By January 31 ❑ July 1 &Received By Judy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING •REMITTANCE f AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE W-1, <br /> 1 LESS <br /> PRORATION y <br /> PLUS <br /> PENALTY v{ <br /> ` u J S <br /> L OTHER Y �• <br /> 41t 60- ric <br /> i Receipt o. Permit No jsivanc6 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 />