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� .. Applications Will Be Processed When-Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY L <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 application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San J aquin Local Health District. <br /> Exact Site Address? V p g.Q o e)(- 33,7'10 ko; etn Rai-City/Town � � •' <br /> Owner's Nam O Phone �- <br /> Address City o <br /> Contractor's Name QLicense# 3 2-1 �� Business Phone <br /> Contractor's Address 300 S 1 lw Emergency Phone <br /> Is Certificate of Workman's CompensationIn rance on File With SJLHD? Yes No 0' <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V�++ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Q Sewer Lines _- Pit Privy 1� <br /> Sewage Disposal Field (0 Q' 't Cesspool/Seepage Pit , Other i v� <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL U <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 Sejl <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout ILPi� // <br /> El DISPOSAL 11 OTHER Other Information t&.b by 0_4"� <br /> ❑ GEOPHYSICAL Surface Seal Installed By: owil py- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done �1 <br /> PUMP REPAIR: ❑ State Work Done <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. I <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 4 �� <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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I=t for a Grout Ition prior to grouting and a final inspection. <br /> Signed X Title: Date: Z—d <br /> ,ef6r—aw Plot Plan on Reverse Side) . <br /> FORD ARTME USE ONLY <br /> PHASE <br /> Application Accepted By Date 7� <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 'YPER SITE ❑ EACH ❑ January 1-&Received By January 31 ❑ July 1 &Received By July 31 � <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED' <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i 777 91 5J 21 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH;PERMIT/SERVICE$ 1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON,CA.9520 <br />