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Applications Will Be Processed'When Submitted Properly Completed. Be Sure.To Sign The Application. <br /> FOR OFFICE USE: APPLICATION y. ; <br /> ! r.-rCd_1b 16" 0 Ilk (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> s <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinanc No. 1862 and the rules and regulations of the San Joaquin Lo Health District. <br /> Exact Site Address .S •S� -f'. City/Town <br /> 4 <br /> Phone s <br /> Owner's Name <br /> Address <br /> S'~ -ae'� City <br /> Contractor's Name 62 > License# ":3 7a.,.,1�1Tusiness Phone <br /> Contractor's Address 02000LEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File W th SJLHD? YesNo . <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN Of. RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR( <br /> IzS <br /> REPLACEMENT❑ it I, <br /> DISTANCE TO NEAREST: Septic Tank. Sewer Lines Pit Privy v <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line l Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ 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 } <br /> ❑ DISPOSAL ❑ OTHER Other Information _f <br /> ❑ GEOPHYSICAL ' Surface Seal Installed 13,4,1 <br /> PUMP INSTALLATION: Contractor & &.. <br /> Type of PumpCO <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 19 State Work Done a—A ALJ <br /> DESTRUCTION OF WELL: Well Diameter Approximdte Depth '4 <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 Sari Joaquin-,Local Health District. <br /> Home owner 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 foliowing:"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 Inspectio�ielfr ou kand a final inspection.) t <br /> Signed X- C4� llle: .�' Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT U E ONLY <br /> PHASE 1 '/ Date <br /> Application Application Accepted By <br /> Additional Comments: ' <br /> Phase II Grout Inspection Ph Iltr nal Inspection <br /> Inspection By Date Inspection By Date <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By <br /> `REMIT <br /> e EXPLANATION BILLING REMITTANCE $ - ] ­ <br /> BASE -1a_GHEGKED_DATE DATE # REMITTEDAMOUNTDUE-- <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION' f <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> a <br /> { 1 <br /> OTHER - <br /> Received by Rate Receipt No. - -Permit N Issuance Date Mailed Delivered - - <br /> APPLICANT—RETl1RN ALL COPIES TO: ENYIRONMENTAL HEALTH PERMITISERVICES .1601 E:HAZELTON AVE.,P.O.Box 2009 ;,STOCKTON,CA 95201 <br />