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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 /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Swan Joaquin County rdinance No. 186?7d he rules and regulations of the San)oaquin Local Health Dis%ict. <br /> Exact Site Address �zv . : ! City/Town <br /> Owner's Name 's t ' Phone `s <br /> Address � F' r:;t-,f» ,,F«; _ - f"_: t Cit <br /> Contractor's Name S2h -% '.v:^��� r r: �• <br /> Arra;„= License ,,fi..� .��� Business Phone__ <br /> Contractor's Address "`7 C Ki. -- C`-=r=f 3". ' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Noi <br /> TYPE OF WORK (CHECK): NEW WELL C-- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 13 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0—'PUMP REPAIRO j# <br /> REPLACEMENT❑ <br />' DISTANCE TO NEAREST: Septic Tank f) Sewer Li en s a' /-j 5�"m Pit Privy <br /> Sewage Disposal Field 71471. Cesspool/Seepage Pit Other <br /> Property Line /-.fPrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INpUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> LA"DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ,� <br /> _❑_CATHODIC PROTECTION __ROTARY _ Type-of-of <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 'Y <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 accord ce with San"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 perfornriof 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 em toy persons subject to workman-is compensation laws of California." <br /> will call for a Grit 1h p tion' rior to grouting and a final inspections J <br /> Sign Title: Co �r (VI r* Date: <br /> (Draw Plot Plan on Reverse.Side) - <br /> FOR DEPARTMENT USE-i r T <br /> PHASE I <br /> - - .. . .. - (16 <br /> Applica-tion-' Accepted-- -- `✓ <br /> By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspecilon <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 /> 91 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - --� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, _ Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH.PERMIT/SERVICES"',e. r-- Iii E.HAIELTON AVE.,P.D.amc 2009 STOCKTON,CA 95201 <br />