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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> FOR 6FFl--cE7tJS E: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or installthework herein described.This application is <br /> made in compliance with San Joa in County�O+rdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addres � �� �' 1 C,-,6 LL& City/Town C;-IIL L 7- <br /> Owner's NamPhone .3�V <br /> Address ^ 7d A.) • A_ City <br /> 2� <br /> Contractor's Name }YllL4�t� b°�- �J�ll 3`fi r� ease# �4����-3 Business Phone l` 7,47 <br /> Contractor's Address .1 ou0 I _1_-W�1Cs ,�cEmergency Phone 3 4 F —/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 5 W <br /> TYPE OF WORK-(CHECK): NEW WELL 11 ❑DEEPEN RECONDITIONDESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ I <br /> REPLACEMENT❑_ <br /> DISTANCE TO NEAREST Septic TanklA��3� Sewer Lines ` Pit Privy A) <br /> Sewage Disposal Field Cesspooll/Seqpage Pit P42- ter N Lj/%WProperty Line 1�Private Domestic Well 4V�„ , CPublic Domestic Well Z w. <br /> ! r <br /> 99 6/_0—P de <br /> INTENDED USE TYPE OF WELL .* <br /> ❑p <br /> � L / o2p p . <br /> r,.� INDUSTRIAL 1KCABLE TO Dia. "W <br /> ofell Excn <br /> avatio ' <br /> !KE DOMESTIC/PRIVATE ODRILLED Dia. of Well Casing p �i <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 'I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY _ _ Type-of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL _ Surface-Seal,Install d By: -r (1- e- <br /> PUMP INSTALLATION. Contractor �.D 1A J, Liz y �r�cs� ��^ 0-zv--eCe, <br /> Type of Pump /��l�'1J In - H.P. Jr <br /> PUMP REPLACEMENT: El State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> t - V <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.L_ocal Health District, I <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 /> I 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 certifles the following:"I 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 Cali"fornia." <br /> it � -,.. <br /> 1 will call for a Grout Inspection pr' r to grputing and a final Inspection. f S <br /> Signed X Title: t-�/ Date: <br /> r (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 5' re S <br /> PHASE I <br /> Application Accepted By Date !�4 <br /> Additional Comments: <br /> a II Grout Inspection h Aa <br /> sh If <br /> in Inspection <br /> Inspection By Date _ r [ Inspection By <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT,. , - ❑,PER_SITL� ❑ EACH ll January i &Received By January 31 El July 1 &Received By July 31 <br /> -�- - .-. REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED - AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1 <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONAVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />