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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 /> V PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , <br /> Application is hereby made tothe San Joaquin Local Health Districtfora 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 r les and regulations of the San oaqul }ocal Health District. <br /> Exact Site Address l[7 4 2.eo -►'- ! .Q City/Town <br /> Oi <br /> Owner's Name r -.04 4"�? A"de lit& �t7 Phone <br /> Address J-2-5%- i0 ��xxt`T etr City CA �-� I <br /> Contractor's Name S�°��r7 Its License# Business Phone <br /> Contractor's Address --'2Q Emergency Phone <br /> Is Certificate of Workman's Compensate n In urance 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❑ <br /> REPLACEMENT❑ p1. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well h/ <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 Q <br /> ❑ GEOPHYSICAL = Surface Seal Inst led By: _ Q� <br /> PUMP INSTALLATION: Contractor '(S�'�'O C-Gl 57. G,� <br /> Typeof Pump H.P. + } <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP RePJx'IFf: State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <br /> #x Describe Material and,Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance ofthe work forwhich 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-cont"racting 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 corripensation laws of California." <br /> I w'II call for a Grout Inspec ' P .O o uting and a final inspection. <br /> Signed itle: Date: v <br /> (Draw Plot Ian on Reverse Side) ` <br /> - i <br /> FO DEPARTMENT U E ONLY I <br /> PHASE / <br /> Application Accepted By ^" / Date �G <br /> Additional Comments: <br /> Phase 11 Grout Inspection I F' aa pectianInspection By k = ,Date Inspection Byh / <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT I <br /> BILLING REMITTANCE $ F <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ;f <br /> AMOUNT <br /> FEE <br /> u <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> V, <br /> Received by Date Receipt No. Fyermit No. - Issuance 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 />