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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION �— <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WE!_l. <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�wl'th San Joaquin County Ordinan a No. 1862 and the rules and regulations of the San Joaquin L Cal Health District. <br /> Exact Site Address IM1/EST OF L�Cci ►e►. C_ City/Town <br /> Owner's Name T L ! C m Phone S , <br /> Address City A N <br /> Contractor's Name Il ALL 1V41 License A*MM-5 Business Phone <br /> Contractor's AddresP.0ency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ 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 LinePrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 7 // <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Wel! Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION C1 GRAVEL PACK Depth of Grout Seal <br /> C-1 ��yr <br /> CATHODIC PROTECTION Mi ROTARY Type of Grout <br /> ❑ DISPOSAL ( Iap�C, �'�+ ❑ OTHER Other Information <br /> GEOPHYSI4b IDE QA.�Olk� <br /> CA Jd[[�4 �'�rJ-2� Surface Seal Instal{ed B 0 <br /> PUMP INSTALLATION: Contractor C e- �� <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: ❑ State Work Done <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 accordance with San Joaquin County �5 <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 thework forwhich 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." <br /> I ra�llrGr u Inspection�pnorogrouti�and final Inspection. QSigned X Title /a �T -ADates�'� •+® <br /> (Dralan on Reverse de) /, Z:F*Af 14-37 <br /> w <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ -0Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout InspectionPas I Final Inspection !3 <br /> Inspection By Date Inspection By LV�^Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE RE`MIrrTTED AMOUNT <br /> FEE �3 "Y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 710 a-7s4.3 <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 />