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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> i. FOR OFF!_.PE USE: Il , APPLICATION <br /> = �oky_��p'�B�"• (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL / <br /> may.-A--- ENVIRONMENTAL HEALTH PERMIT <br /> w (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 Cott�ty Ordinance No 18C12 and the rules and regulations of the San J4in Lo al Health District. <br /> Exact Site Address �/ �� City/Town <br /> Owner's Name t/ fr Phone <br /> Address rfOZ-1 C- A +h �Z ey, Cit r1 <br /> Y � <br /> Contractor's Name License#_/�3 �'� Business Phone a. <br /> Contractor's Address rte` Emergency Phone q� <br /> Is Certificate of Workman's Compensation Insurance on F' e LHD? Yes - f�...� No <br /> TYPE OF WORK (CHECK): NEW WE LL❑ 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 /> ❑ 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 Seal Installe.0 By: <br /> PUMP INSTALLATION: Contractor r 3 <br /> Type of Pump_ �.7-rc?� _ H.P. <br /> w PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work bone4 - •� a <br /> r <br /> DESTRUCTION OF WELL: Well Diameter IApproximate Depth <br /> Describe Material and Procedure <br />'r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County J <br /> J 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 certifythat 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ww II call fo/r a Grout Inspection .rior gr in nd-a final inspection. <br /> Signed �Ok�9;�1 ' u� e: E`3� _ <br /> Date: � <br /> (Draw f lat P n on,Reverse Side) <br /> FOR DEPARTMENT USE ONLY v—ISI <br /> PHASEI I ` 7 <br /> Application Accepted By ,J - -11.10"-Dateg� t <br /> Additional Comments: d�.. <br /> Phase II Grout Inspection a e III F' al Inspection _ <br /> Inspection By Date Inspection By. Date �� �� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 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 f <br /> OTHER <br /> OTHER <br /> Received by Date _4,¢ Receipt No. -,. Permit No.. - - ssuane Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - EiNVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 rrSTOCKTON,CA 95201 <br />