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Applications Will Be Processed When Submitted Properly Completed..Be Sure To Sign The Application: <br /> FOR OFFICE USE: APPLICATION, <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT e) <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 Local Health District. <br /> Exact Site Addresses r City/Town R,, E4.L�a I' <br /> •Y _ I <br /> Owner's Name <br /> Phone 1 <br /> Address -Cv `61 --� City <br /> Contractor's Name Y License( _7 ("Business Phone ' <br /> Contractor's Address e i y -. .Emergency Phone - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes z_--- No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑.. "DESTRUCTIONN❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑. OTHER ❑ PUMP INSTALLATIONS PUMP REPAIR❑ U <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 /> ❑ IND STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> , <br /> `DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing (� ` <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal O� <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grout J, <br /> ❑ DISPOSAL 11 OTHER Other Information C/) <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done,/-, <br /> on .> �I <br /> PUMP REPAIR: ❑ State Work Done a <br /> 4.�;Y 0. �1 <br /> DESTRUCTION OF WELL: Well Diameter - -� Approximate Depth <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 /> Homeowner or licensed agent's signature certifies the following:"1 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'sflring or sub-contracting signature certifies the following:"I certify that in the performance of the work for ywhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> !will call fora ut Inspection rior to grouting and a final inspection. <br /> Signed X Title: .. Date: _Z0.'7-75P <br /> (Draw Plot Plan on Reve se Side) <br /> FOR DEPARTMENT USE ONLY !r <br /> PHASE I r <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection mal Inspection <br /> Inspection By Date Inspection By Date % <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> it <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY r . <br /> OTHER _- <br /> 1?- <br /> OTHER I <br /> Received by, Date Receipt-No. Permit No. _ Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />