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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) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT v <br /> (COMPLETE IN RIPLICATE) WATER QUALITY <br /> Application is her by mad <br /> etothe S'anJoaquin Local Health District for apermit toconstruct and/or install the work herein described.This application is <br /> made in complian a with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addrest!S s�� -�a �-�45 -�-� City/Town [-�-� <br /> r' <br /> Owner's Name �� Phoneme <br /> Address City__ - <br /> Contractor's Name License#?�, 71 Business Phone '7. <br /> Contractor's Address EC� > ��� „� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <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 /> r ` <br /> INTENDED USE TYPE OF WELL <br /> ❑ 11y�lJSTRIAL ❑ 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 <br /> ❑ GEOPHYSICAL � � Surface Sea�alled 13y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> -_ PUMP REPLACEMENT: ❑ State Work-Don <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> t 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:"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 /> L Contractor's hiring or sub-contracting signature certifies the following:"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 wit f r a Grout Inspection prior to grouting and a final inspection. / <br /> F Signed Title: QtTm�d A' Date:--9 <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: ZP <br /> '. <br /> j Phase II Grout Inspectionase III Fi I Inspection <br /> r <br /> Inspection By Date Inspection B Date — _2-J- <br />' Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> IBILLING REM#TTANCE $ REMIT <br /> BASE` EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY <br /> f <br /> l OTHER <br /> I OTHER <br /> %'Received by..—'— n Date Receipt No. Permit No. - Iss ance Date Mailed Delivered . <br /> •APPLICANT=RETURN AL'L COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.H_AZELTON AVE.,P.O.Box 2009 STOC1cTON,CA 95201 <br />