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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F_O_ OFFffCE USE: APPLICATION 3 <br /> (For Non-Translerable, Revocable, Suspendabte) <br /> pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALI Y <br /> (COMPLETE IN TRIPLICATE) <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 applicatior <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sar: Joaquin Local Health District, <br /> Exact Site Address -26 /w ;EW, City/Town r� <br /> Owner's Name &X IA T Phone Oa <br /> i <br /> Address 5 5� S, City Ge"o-Z j <br /> Contractor's Name 4� ,Al LicenseBusiness Phone <br /> Contractor's Address Emergency Phone 5 " <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_,)<' No <br /> TYPE OF WORK (CHECK): NEW WELL C1DEEPEN RECONDITION u DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR R4 <br /> REPLACEMENT _. : w 7� <br /> DISTANCE TO NEAREST: '- Septic Tank d "" - Sewer Lines" <br /> .'Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 4 <br /> Property Line lei- Private Domestic Well t=— 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 f® y <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ld ) <br /> IRRIGATION ❑ GRAVEL PACK. Depth of Grout Seal <br /> ElCATHODIC PROTECTION 11ROTARY y r Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information �S��NC <br /> 11 GEOPHYSICAL Surface Seal Installed By: _ E <br /> PUMP INSTALLATION: Contractor <br /> H.P. I <br /> Type of Pump <br /> \ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work:Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth .. <br /> Describe Material and Procedure <br /> F <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 /> 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 /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi call fora out Insp tin or to grouting and a final inspection. <br /> Signed X <br /> Title: df Date: <br /> (Draw Plot Plan on Reverse Side) , <br /> F R D ARTME USE ONLY <br /> I PHASE I <br /> Application Accepted-By Date LI <br /> Additional Comments`: <br /> Phase II Grout Inspection _/ P I Final I spection � <br /> Inspection By Date �Y 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 July 31 <br /> REME7 <br /> 'BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE rC4.11t dr <br /> LESS <br /> PRORATION 4 <br /> PLUS i]� <br /> PENALTY 1! <br /> OTHER _ <br /> OTHER q <br /> Received by at eceipt No. Permit ho. - Issuance Date ailed Delivered - <br /> k <br /> S <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P. .13x/2009 STOCKTON;CA 95201 <br />