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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ..�..O' OFFICE USE: A <br /> I PPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) r <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> QUALITY <br /> TER ' <br /> (COMPLETE IN TRIPLICATE) WAQ <br /> f Application is hereby made tothe 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 <br /> �San Joa�r u;�in//Cou�nty� yO�rd-ynance No. 1862 a/nd the rules and regula 'o of the San Jo,�a�jj��uin Loral He Ith District. <br /> Exact Site Address S8I5�l�L(,IS =W�St Q/ .� 'ty7Town l20m 4(� <br /> `' v )1 a N <br /> Owner's Name /�?om4?,:nan en1.SzJr(.Ce1T in Phone _213—91p, <br /> Address . A /yfxsox '2413 City /�Ct,o AOea <br /> Contractor's Name ,,,/� License# „24DS1�3 Business Phone_ <br /> Contractor's Address L Se�S p�� o. CiCP.S� Emergency Phone c5 5= 7/ <br /> Is Certificate of Workman's Compensationnsurance on File With SJLHD? Yes No <br /> I TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /00 'Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> ✓ r <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> %DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 4 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> II ❑ IRRIGATION <br /> GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> l ❑ DISPOSAL ❑ OTHER Other Information - <br /> [ y l <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> .Type of Pump y� � - 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 , r . <br /> I 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 pertormance of tine work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection prior to grouting and a final inspection. ,,, <br /> Signed X f Title: '�/t. Q 4 Date: ��� <br /> Draw Plot Plan on Reverse Side) <br /> X e FOR DEPARTMENT USE ONLY <br /> PHASE i �4_ <br /> Application Accepted By Date <br /> Additional Comments: <br /> h rout Inspection / Ph as I Final Inspection <br /> Inspection By Date- 1 Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ece,ved By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> -LESS- <br /> PRORATION <br /> LESS 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 TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9 <br />