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Applications Will Be Processed When Submitted Properly compieiea. o� _ <br /> FOR OFFICE USE: 1 APPLICATION <br /> (For Non-Transferable,Revocable,Suspendabfe) PUMP&WELL �( <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address l f-rr !1� 47"! IllEV/ ,ice City/Town PAC�J <br /> Owner's Name i,AlA,C -E Phone <br /> Address Jryj q t�4PSltitS s1fE Gity F✓ - <br /> Contractor's Name L �IJi4 � /___ � License# :3 Business Phone <br /> Contractor's Address Emergency Phone t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo _ <br /> TYPE OF WORK (CHECK): NEW WELL, DEEPEN ❑ ' RECONDITION DESTRUCTION❑ _ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ _ <br /> I DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field---ZOO A=T Cesspooi/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> ❑ CABLE TOOL Dia. of Well Excavation 12„ <br /> IWDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing --6,n E[T <br /> ❑ IRRIGATION 64 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout tf�li/ 7�i1�7 <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 Done V <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 'tee <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 of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to beton a 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 subject fo workman's compensation laws of California." <br /> I will call fora G out Insp tion prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plat Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> - PHASE I r. �f <br /> Application Accepted By �/ v—z^' Date <br /> Additional Comments: 1 <br /> fia e I 1 rout Inspection Phase 1 I 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 /> BASE EXPLANATION `BILLING REMITTANCE $ AMOUNT OLfE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S I <br /> LESS } <br /> PRORATION { <br /> PLUS ' <br /> PENALTY <br /> OTHER • ' ..Y. <br /> OTHER <br /> Received by Date Receipt No. Permil No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTI4 PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95Y01 <br />