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Appy cations Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> '�° j APPLICATION <br /> FOR OFFICE USE: & 0 1 i <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL t <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Distric'tfora permit to construct and!or install the work herein described.This application is f <br /> made �_--}co� ��,,��e�rwith San•Joaquin-County rdinanc a No. 1862 and the rules and reg lations of the San Joaquin Local Health District. <br /> Exact iAli, A �rerss' �i/111� Fe u cs O/` �F kJ f+sl�°City/Town <br /> �/ � �� G I¢CLG`/f1G�¢ /f� Phone trJ <br /> Owner's Name <br /> �. F�L7iEi6 ,�4 37 <br /> City <br /> Address �j391 <br /> Contractor's Name r LZ 'Elt�z ! Q f License# �G/� Business Phone G <br /> �L��.o Emergency Phone "Acfr� <br /> Contractor's Address <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> G <br /> TYPE OF WORK (CHECK): NEW WELL Kul DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ O� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <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 /> Ili INTENDED USE TYPE OF WELL <br /> ❑ <br /> �CABL�E TOOL Dia. of Well Excavation <br /> INDUSTRIAL <br /> Dia. Well Casing <br /> ❑ DOMESTIC/PRIVATE C3 DRILLED a 1 <br /> 11DOMESTIC/PUBLIC 11 DRIVEN <br /> Gauge of Casing <br /> Depth of Grout seat <br /> �iRRIGAT1 13 GRAVEL PACK <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> 11 OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> j PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. _ ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> r ; Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 /> I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof 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." i <br /> Contractor's hiring or sub-contracting signature certifies the following:"1 certify that in the performance of the work for which this <br /> permit is issued,'l Shall.employ persons'subject to workman's compensation laws of California." <br /> r I 'I c 11 for a Grout Inspection prior to grouting and a sinal inspection. <br /> Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II G 1 Inspection ase-III n spection <br /> Inspection By Date Inspection By e <br /> 1 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ <br /> July 1 &Received By July 31 <br /> h BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ' BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> i <br /> FEE P3 00 Zi-3°a <br /> LESS <br /> I PRORATION _ <br /> PLUS <br /> PENALTY <br /> f OTHER t <br /> OTHER <br /> c. 1�a3T o <br /> Received by <br /> Date Receipt No. Permit No - Issuance Date Mailed Delivered <br /> r HEALTH PERMITlSERVICE5 - 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCNTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL <br />