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Wpplications Will Be,Proc�ssedWhenSubmitted Properly Completed. Be Sure To Sign The Application. <br /> ',� <br /> FOR OFFICE USES" ( APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> 1`ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATt) WATER QUALITY <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 Joaqu'Vk Countyrdina a No.1862 and the rules and regulations of the San JoaquinLocal Health District. <br /> Exact Site Address �G f7C3 , City/Town * dpa4A_ <br /> Owner's Name f Phone � <br /> Address City <br /> Contractor's Name <nfL47License# Business <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes J_.4_1_1 No t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ R'ECONDITION❑ DESTRUCTION❑ --� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestiell Public Domestic Well <br /> INTENDED USE TYPE OF WELL, <br /> ❑ INDUSTRIAL i ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE' . ❑ DRILLED- Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN '7-'.."-7. Gauge of Casing ' <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY —Type of Grout <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL S - ' {^Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C F <br /> Type of Pump H P.!5' <br /> ^ <br /> PUMP REPLACEMENT: State Work Done iG1m.ZZ <br /> PUMP REPAIR: ❑ State Work Dane <br /> DESTRUCTION OF WELL:tea Well Diameter / Approximate Depth.-- <br /> ' N" Describe Material and Procedure �•�tJ��� n .tel-�-� <br /> VI 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. r <br /> L <br /> Homeowner 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 become subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-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 /> S <br /> I will jiall for at Inspection prior to grouting and a final inspec' <br /> Signed X RL l /.� Title: _ �� Date: <br /> (Draw Plot Plan on Reverse Side) t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By - Date Z <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection C L 7 <br /> Inspection By Date Inspection By Date -5lt 1 a J <br /> Fee Is Due: El ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE TED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 1 S <br /> LESS 01 <br /> PRORATION <br /> PLUS a� /�i f <br /> PENALTY CALL - <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I uance nA46, Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />