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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOWOFFICE USE: APPLICATION r <br /> (For Non-Transferable, Revocable,Suspendable) 5 <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hegeby madeto the San Joaquin Local Health District fora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San'J�o,aq/uin County Ordinanc%No. 1862 and the rules and regulations sof the an Joaqui-p Local Health District. <br /> Exact Site Address o C1 J%--- tC � Au /_0 f � YJfov TDLIt/ � lea- 41A__z <br /> Owner's Name t Phone <br /> Address r~ City '- <br /> ContractiOr's Name ` License#; o4l9d,?13 Business Phone z;­ <br /> Contractor's Address Emergency Phone —� 7 <br /> Is Certif•cate,of Workman's Compensation Insurance on File With SJLHO? Yes X _ No <br /> TYPE OF WORK (CHECK): NEW WELL U?'*'� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ - <br /> REPLACEMENT❑ ! v , <br /> DISTANCE TO NEAREST: Septic Tank /00 _ Sewer Lines Pit Privy <br /> Sewage Disposal Field IOD Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL N <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - <br /> DOMESTIC/PRIVATE El DRILLED Dia. of Well Casing �1 pY <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 r <br /> 11 GEOPHYSICAL Surface Seal Installed By: fl <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump Q <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. �t <br /> Homeowner or licensed agent's signature certifies the following:1 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c It for a Grout Ins ectio r to grouting nd a final inspection. <br />'I Signed X Thie: - Date: ►' <br /> (Draw Pt Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> Application Accepted By !��e�� 'a- <br /> Additional Comments: <br /> I' se II Grout In ection IVVfina n e tion r <br />€ Inspection By �3 Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 ❑ July 1 &Received By July <br /> i <br /> BILLING REMITTANCE $ REMIT SASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE s2t 113 > '-T <br /> a <br /> LESS <br /> PRORATION <br /> F PLUS /- <br /> PENALTY <br /> F OTHER ' <br /> I OTHER <br /> Received by ate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL'HEALTH PERMIT/SERVICES 1601 E.HAZELTONAVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />