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- Applications Will Be Processed When Submitted Properly Completed. Be Sure TO Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ■' (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) W� TER QUALITY 0-71 l7 <br /> ,c80 u1 r�+4•�c ; <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 No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address RP'W�m4axxw_ • City/Town S �J <br /> \ t <br /> Owner's Name r�r*0rA6 ] � Upt' �x��w + Phone �{: �'�2�7 <br /> Address3` eG��t`c�@>L�j,e W�ta City <br /> Contractor's Name C1vcY �fZo� License# "'X- L0cz513 Business Phone <br /> Contractor's Address `�.�_'?- tc�} � Ga�)"� 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 REPAIR❑ V <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other Jj <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 1 Type of Grout <br /> ❑ DISPOSAL .59 OTHER �j� �('q�1t2 Other Information - <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 1 <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 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 /> a <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 Inspection prior to grouting and a final inspection. <br /> fig, i <br /> Signed Title: d\_ ____ _ Date. � <br /> I ( raw Plot Plan on Reverse Side) <br /> n <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> i' <br /> PHASE I l <br /> 1 <br /> 9) <br /> Application Accepted By Date <br /> I Additional Comments: <br /> Phase If Grout Inspection y Phase III Final Inspection <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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> � AMOUNT <br /> FEE 41 <br /> LESS <br /> PRORATION <br /> lip 1 4 n$11- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l� �Y 078 1 15? (0 <br /> eceived by Date Receipt No. Permit No. ' Issuan a 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 />