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p ca o15s I - _rocessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR.!PFFICE USE: APPLICATION s <br /> (For Non-Transferable, Revocable, Suspendable) 11 <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE)-lZ.7&:F( -WATER QUALITY <br /> Application 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 Joaquin County Ordinance'IVp. 1862 and#)le ules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address %Vd ® 14 City/lawn <br /> Owner's Name, �- <br /> �i <br /> Address Phone <br /> City 1 <br /> Contractor's Name -4�14-IVb- .�i C License 40-77X Business Phone " <br /> Contractor's Address A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIPX <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 f <br /> ❑ INDUSTRIAL ❑ <br /> CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing F <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ' <br /> )K IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H_P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter - Approximate_bepth <br /> Describe Material and Procedure <br /> I herebycertify that I have p pp iK <br /> Y 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 forwhich this <br /> permit is issued, I shall employ persons bject to workman's compensation laws of California." <br /> I will c for a Grput Inspection prior grouting and a final inspection. <br /> Signed ­-Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I x x <br /> Application Accepted By ©� <br /> e <br /> Additional Comments: Dat <br /> Phase It Grout Inspection ha II ial I ion <br /> Inspection By Date Inspection By Date <br /> Fee Is Due; ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS - <br /> PRORATION l <br /> PLUS is <br /> PENALTY <br /> OTHER <br /> x - <br /> OTHER <br /> g - �a `z' ��� ( 7q q <br /> `.. <br /> Received by - Date Receipt No. - Permit No, ssu ce Date },Mailed -Delivered <br /> T APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - - 16101 E.HAZELTON AVE.,P.O.Box 2009=STOCKTON,CA 95201 <br />