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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 /> l PUMP&WELL - <br /> ENVIRONMENTAL HEALTH PERMIT <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 San Joaquin C,unty Ordinance No. 1862 and the rules and regulations of the San Jooa�uin L al-H alth District. <br /> Exact Site Address 3.I W OW IRDIND City/Town Jt u +( 'y frZO (e +? <br /> Owner's Name A&w Phone # <br /> Address '7'L"7 W W City <br /> Contractor's Name L L u 1P fir_ License# &0 Busingss Phone i•� 'S,T� <br /> Contractor's Address t. _ Emergency Phone NI�i <br /> Is Certificate of Workman's Compensation Insur a on File With SJLHD? Yes_V_.0No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL !eu <br /> ❑ INDUSTRIAL ❑ CABLE TOOL 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 F ROTARY Type of Grout '�EWf�u ITS <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 p' <br /> PUMP REPAIR: ❑ State Work Done _ f <br /> DESTRUCT Well Diameter 6 _ Approximate Depth <br /> r Describe Material and Procedure ve-! L_ <br /> I hereby certify that I have prepared this application and that the work will be"done in accordance with San Joaquin County t <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 i ued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> C ractor's hirin ub-contrac 'ng signature certifies the following:"I certify that in the performance of the work forwhich this <br /> P r it is issued I sha employ rsons s jest to workman's compensation laws of.California." <br /> I call for a ut spe i p io to outing and a final inspection. Q /� <br /> Signed X Title:S*_q_--F4gA ) "-M—Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . ` J <br /> Application Accepted By Date i7 <br /> Additional Comments: <br /> Phas�11 Grout Inspection ! .70PPe Phj a 11 Final nspection <br /> Inspection By Date�sT`�� � pec-tion By �" ate <br /> f- ` � r <br /> Fee is Due: ❑ ANNUALLY ❑ P UNIT ❑ PER SITE ❑�^ ❑ January"1 &Received By January 31 ❑ July 1 &Received By July 31 .1 <br /> - _ <br /> BILLING HEMITTANCE REMIT <br /> $ <br /> BASE EXPLANATION DATE DATE' REMITTED AMOUNT DUB`_ CHECKED <br /> AMOUNT <br /> FEE C �� <br /> LESS <br /> PRORATION 0 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER i <br /> Received by -Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />