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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r FOR OFFICE USE: j APPLICATION <br /> (For Non-Transferable, Revo able, Suspendable) PUMP&WELL <br /> ENVIRONMENT'AL`HALTH"PERMIT <br /> (COMPLETE IN TRIPLICATE) ,WATER QUALITY, <br /> Application is hereby made to the 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 San Joaquin County p din ce/No. 18 d the rules d regul Ions of the San Jo Loca He th Di rict.,,, <br /> Exact Site Address �S 7W 4 � fG or r/"/(��f_- �40 ity/Town ' � �- <br /> 11,—e <br /> � v .. <br /> Owners Name ��0 A t/�✓S CJ'K� M t_ t _ Phone-, r- 1• <br /> r Address �o r r r City * . G.. <br /> a Contractor's Name t ti' Llcerise# Business Phone �-146 2- <br /> Contractor's <br /> Contractor's Address r Ce Gt '1 14( Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No a <br /> TYPE OF WORK (CHECK): NEIN WELL9�" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2'�_PUMP.REPAIR❑ <br /> REPLACEMENT❑ E <br /> DISTANCE TO NEAREST: .Se ; Tank; Al>� Sewer Lines Pit Privy } <br /> Y xSewage Disposal Field Cesspool/Seepage Pit 0 it <br /> Property Line Private Domestic Well _T�. Public Domestic Well <br /> INTENDED USE TYPE Of WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL F Dia. of Well Excavation,_,s/ <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia_of Well Casing, <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Ca Is ng - <br /> ❑ IRRIGATION R GRAVEL PACK Depth of Grout Seal " <br /> V <br /> ❑ CATHODIC PROTECTION 2-ItOTARY' Type of Grout <br /> ❑ DISPOSAL IT OTHER Other Information ty�. <br /> ❑ GEOPHYSICALurface_Seal talled By: t 1 Q U , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump sN.P. . - - <br /> +�k <br /> PUMP REPLACEMENT: ; ❑ State Work Done g.r , <br /> PUMP REPAIR: ❑ State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 3� <br /> Describe Material and Procedure.. r �� <br /> 1 �I hereby certify that I have prepared this application and that the-work wish be done •inlaccordance with San Joaquin County . <br /> ordinances, state laws, and rules and regulations of the San Joaquin'Local`Nealth_D'(S.ict. <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 subjec,to workman's compensation laws oPGalifornia." <br /> 1 ontrac hiring or sub-coni ting tuie certifies the following:"I certify That in the performance of the work for_lnilijdh this <br /> permit 's is T , I Thal empl r s ubj ct to'wo`rk'man!,s compensation laws of California." <br /> I wil - a Gro n o-grou g an '�aTin'spection. <br /> 00, <br /> tl :Teu�Signed <br /> R (Draw Plot Plan on Reverse Side) - <br /> FOR DEPARTMENT USE ONLY"� i <br /> PHASE I f .. ; - r <br /> E� <br /> Application Ac pte By Date �r7 <br /> Additional C nt <br /> i <br /> i se out Inspectipn �! ? eReceiv6d <br /> ase Final In pection <br /> F Inspecti 8 � Date Inspecti nDate �`�� <br /> 1 Fee Is Due ANNUALLY ❑ PEA UNIT. ❑ R'SIT i ❑ EACH ❑ January 1By January-31."T- �❑ July 1'&Received By July 31 - <br /> I,-� . REMIT <br /> 1 <br /> F BILLING REMITTANCE. $ <br /> BASE - EXPLANATION AMOUNT DUE CHECKED <br /> DATE i , =v�D�Al;E rl{" F�,r '-tjEMITTED AMOUNT <br /> FEE: <br /> + <br /> LESS .h t <br /> PRORATION <br /> PLUS <br /> - PENALTY .,; f { <br /> OTHERS <br /> c <br /> OTHER <br /> S <br /> Received by, - -. Date Receipt No. Permit No `.I uanc Date - Mailedv. Delivered' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONINENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />