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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> C16'*itl16 (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 Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Lo al H,ealth District. <br /> Exact Site Address �IeZR <br /> = Y) City/Town [�•�.�- <br /> Owner's Name + b4t,,r+ At k1 0 41� Phone <br /> Address City <br /> 7od 7Z <br /> Contractor's Name a "ZD License# 1� 7�_.._ Business Phone 1 <br /> Contractor's Address Emergency Phone <br /> 1s Certificate of Workman's Compensation Insurance on File Wi h SJLHD? Yes X No O� <br /> TYPE OF WORK (CHECK: NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ 016 F <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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 06 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 i <br /> ❑ DISPOSAL ❑ OTHER Other Information j <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ..� % r 001 <br /> Type of Pump a v 14 U. H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done t�t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth I <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> i <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work 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 III call for a Grout Inspec n'_pr- r Ing and a final inspection. <br /> Signed � life: R Date: <br /> (Draw Plot an on Reverse Side) <br /> l - . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase Il Grout Inspection P a I Fiflal I pection <br /> Inspection By Date inspection e <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jan ry 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> �4 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> O <br /> °° D <br /> 5 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS` <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0 3os 10 <br /> Received by Date Receipt No Permit No. Issua ce Date Malted Delivered <br /> Li APPLICANT—RETURN ALL'COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,.CA 95201 <br />