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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) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address{ 0.bgeriH kiarirCity/Town `J''TCXtC"lUltt..! <br /> Owner's Name f� ��2t, -rnGi Phone <br /> Address S/A - ,'. r: .- _, City <br /> Contractor's Name CW e t2' _License# } Business Phone - <br /> Contractor's Address ""� Emergency Phone � — <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes f No ( l <br /> TYPE OF WORK (CHECK):_ NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ '� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑-. OTHER M, —PUMP INSTALLATION ❑ PUMP.REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines �� . Pit Privy r <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line-_2' Private Domestic Well 7d Public Domestic Well _ <br /> INTENDED USE 'TYPE OF WELL 33'A �r5 Ql1?Rl�l P) <br /> ❑ INDUSTRIAL ❑ CABLEyTOOL 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 <br /> ❑ GEOPHYSICAL *Surface Seal installed By: f <br /> PUMP INSTALLATION: Contractor { % <br /> Type of Pump ' H.P. <br /> R f + <br /> PUMP REPLACEMENT: ElState Wowrk Done <br /> PUMP REPAIR: ❑ State Work Done t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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. <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 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 to workman's compensation laws of California." fi <br /> S � , <br /> I II fat's Grout In rior to grouting and a final inspection. <br /> Signed X Title ( Date: � � - <br /> (Draw Plot Plan on Reverse Side) "• „ r . <br /> { FOR DEPARTMENT USE ONLY• <br /> PHASE I r� <br /> Application Accepted Date <br /> Additional Comment I <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date ~' Inspection By Date <br /> € � f . <br /> Fee Is Due: ❑ ANNUALLY [I PER UNIT ❑ PER SITE ❑ EACH - ❑ Sanuarya.&Received By-Januaryll�[:]July 1 &Received By July 31 <br /> BASE i EXPLANATION BILLING. r REMITTANCE $ AMOUNT DUE - CHECKED <br /> DATE DATE, , EMITTED AMOUNT <br /> u <br /> yL � <br /> 00 <br /> FSE . <br /> �� � �: _ <br /> LESS ,rN � � r'' <br /> PRORATION _ if I L-1 <br /> PLUS �L <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> -Received by If Date - Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />