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Applications Will Be Processed When Submitted Properly Completed. Besure iosign Inexppnoauvn, <br /> FOR OFFICE USE: IM' APPLICATION ' <br /> C,1p� P ' (For Non-Transferable, Revocable,Suspendable) <br /> I PUMP&WELL <br /> { ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/or install theworkherein described.This applicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin SOT/ I <br /> L al H It District. <br /> Exact Site Address ,�'4f�l Q rW po d _ City/Town <br /> IY <br /> Owner's Name Phone <br /> k Address ✓+'��Q } City <br /> Contractor's Name �-+a License # Business Phone__ <br /> Contractor's Address 6A_ Emergency Phone <br /> I <br /> Is Certificate of Workman's Compensation Insurance on File With LHD? Yes _ No <br /> TYPE OF WORK (CHECK): NE WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> t WELL CHLORINATION ❑ WYELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO-NEAREST: Septic Tank Sewer Lines Pit Privy <br /> a Sewage Disposal Field "Cesspool/Seepage Pit Other <br /> Property Line Private Dome tiC-Weil+ Public Domestic Well I <br /> + INTENDED USE i TYPE OF WELL <br /> ❑ INDUSTRIAL I ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ; ❑ DRILLED Dia. of Well Casing <br /> ` Gauge of Casing <br /> 11 0'pRIVEN <br /> 11 IRRIGATION <br /> ❑ GRAVEL PACK—! Depth of Grout Seal r S <br /> 13CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> i ❑ DISPOSAL �S ❑ OTHER a Other Information <br /> ❑ GEOPHYSICAL JJ ? Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �T� • J, ' <br /> I Type of Pump kKq,iill H.P. <br /> PUMP REPLACEMENT: I I ❑ State Work Done <br /> PUMP REPAIR: I State Work Done OP 0r: <br /> i # <br /> DESTRUCTION,OF,WELL: i Well Diameter Approximate Depth <br /> i I I 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 DistrictI. . <br /> Home owner or licensed agent's signature certifies the.following:"I certify that in the performance of the work forwhich alit permit <br /> employ any person in such manner as to become subject to workman's compensation laws of Cli€ornia." <br /> is issued,'I shall not <br /> l 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 /> d�_ <br /> I will call for a Grout�lnspec- p or outing and a final inspection. e <br /> Signed X <br /> *1arn le: Date:(Draw Ploon Reverse Side? i <br /> FOR DEPARTMENT USE ONLY c <br /> � I <br /> PHASE <br /> r Application Accepted By! Date <br /> 7 <br /> k. Additional Comments: <br /> Phase li Grout Inspection Phase til Final Inspection t q <br /> Inspection By �N Date Inspection By Date ! <br /> Y Fee Is Due: ❑ ANNUALLY' <br /> g ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEByI July 31 <br /> I II' REMITTANCE $ - CHECKED <br /> EXPLANATION BILLINGAMOUNTIDUE <br /> BASE <br /> DATE DATE REMITTED AMOUNT <br /> I! <br /> r EEE L <br /> i LESS <br /> PRORATION Y <br /> PLUS <br /> PENALTY - <br /> II. <br /> OTHER <br /> OTHER <br /> 3 ? <br /> Received by <br /> Date Receipt No. Permit No. Iss ante Date Mailed. Delivered <br /> r <br /> ik <br /> . . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH pERMITJSERVICES 1601 E.HAZELTON AYE.,p.O.Box 2004 STOCKTON,CA 43 <br /> . I <br />