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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �t <br /> FOR OFFICE USE: / APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> o—M'ALETE IN TRIPLICATE) WATER QUALITY <br /> (C <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct'and/orinstallthe work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No 1862 <br /> 1862 and the rules as regulations of the San Joaqu' Local Health District, <br /> Exact Site Address 3 d� LY �i" 7�e ! City/Town <br /> Owner's Name r' Phone r• �•Y <br /> Address A Art�-- A City <br /> Name 0 License# /%7 ,� Business Phone �6 Z "�ig 71— <br /> Contractor's -Contractor's Address =���urnc, <br /> Emergency PhoneIs Certificate of Workman's Compensatioon File ith SJLHD? Yes .. No <br /> TYPE OF WORK (CHECK NEW WELL❑ 'DEEPEN❑ RECONDITION DESTRUCTION❑ - C <br /> ) <br /> WELLCHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 09 PUMP REPAIR❑ ),J <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 <br /> ❑.INDUSTRIAL ❑ CABLE TOOL. Dia. of Well Excavation <br /> tt % DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia, of Well Casing <br /> 1 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ .IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL_ a Surface Seal Installed By: _ <br /> r PUMP INSTALLATION:. Contractorea <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: 51 State Work'Done <br /> PUMP REPAIR: ❑ State Work Done <br /> -DESTRUCTION OF WELL: Well Diameter ``` Approximate Depth f <br /> Describe Material and Procedure <br /> I hereby certify that l have prepared this application a.nd 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 /> fies the following:"I certify that in the performance of the work for which this perm <br /> Home owner or licensed agent's signature certiit <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 for which this ' <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California.' • <br /> I ill call for a Grout Inspect' pri to grout! and inal inspection. <br /> t, <br /> e: }Date <br /> Signed al : <br /> � - (draw Plot non Reverse Side) <br /> {w FOR DEPARTMENT USE ONLY pp <br /> 6 PHASE I w �.o-V 1 �O"I5-6vZ <br /> Application Accepted By '^'�' Date <br /> i t <br /> Additional Comments: <br /> Aas I Final Inspection <br /> Phase II Grout Inspection Date L 0�� � <br /> Inspection By4 , Date Inspection By <br /> F Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE49 <br /> e s <br /> i LESS <br /> PRORATION 8 f <br /> PLUS <br /> 1 PENALTY <br /> !� OTHER <br /> OTHER <br /> l � /5 y <br /> Received by Date. Receipt No. Permit No. . Iss ance Dae Mailed Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />