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Appticatlons Will be Processed When Submitted Properly Completed. Be Sure To Sign The App:cation. lob f <br /> FOR OFFICE USE: APPLICATION /nI <br /> r Non-Transferable, Revocable, Suspendable) <br /> U <br /> ENVIRONMENTAL PUMP&WELL HEALTH PERMIT _ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaqul n Local Health District fora permit to construct arld/or install the work herein described.This application is <br /> made in compliance with Sen Joa9uln County O finance No. 1662 thg rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address. �;t'. City/Town <br /> Owner's Name y c ed iPhone <br /> Address ` �..� '-��n J' /r 2 City <br /> Contractor's Name =3L1 ' CC— <br /> /, ` License q..2�� —Z Business Phone-3 �iS 1 <br /> Contractor's Address E L.1 �,�L.-1i..._iFmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With LHD7 Yes No <br /> TYPE OF WORK (CHECK): . NEW WELLO , DEEPEN ❑ RECONDITION❑ DESTRUCTIO,ND <br /> WELL CHLORINATION El WELL ABANDONMENT 11 OTHER ❑, PUMP INSTALLATION Z- PUMP REPAIR 13 )— <br /> REPLACEMENT❑ <br /> J_ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy L„ <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 0 <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> W❑ IND STR IAL .0 CABLE TOOL Dia,of Well Excavation, <br /> DMESTIC/PRIVATE 0 DRILLED - Dia. of Well Casing <br /> A DOMESTIC/PUBLIC ❑ DRIVEN - Gauge of Casing <br /> C1 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I❑'1 CATHODIC PROTECTION 13 ROTARY Type of Grout <br /> Y - <br /> DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL -�yJ^ Surfac Seat Installed By: <br /> PUMP INSTALLATION: Contractor f-�`�2'��- .i� �� — <br /> Type of Pump x-� H.P._ L <br /> PUMP REPLACEMENT: .❑ State Work Done t)J <br /> PUMP REPAIR: ❑ State Work Dqne rn <br /> DESTRUCTION OF WELL: "Wetl Diameter Approximate Depth /n <br /> ., Describe Material and Procedure <br /> r <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 slgnalll certifies the following:"I certify that inth.eperformanceofthe work for which this permit Ilt <br /> is Issued. I shell.not employ any Person.in such manner as to become subject to-workman's compensation laws of California." <br /> Contractors 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 will n r a Grout Insp tion prim to grouting and a final Inspection. <br /> I <br /> Signed •L Q C t�, Title: Date: Z`� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> Application Accepted By—OC�C � Date .,/ <br /> Additional Comr{tents: . <br /> Phase 11 Grout Inspection - P e III Fina speetion <br /> Inspection By _ - Date Inspection By Date �s i' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLINGPEMITTANCE f L REMIT <br /> AMOUNTDUE CHECKED <br /> PATE DATE REMITTED AMOUNT <br /> FEE .t, ' <br /> LESS <br /> PRORATION e. ' <br /> PLUS <br /> PENALTY <br /> OTHER t <br /> r <br /> OTHER <br /> Received by Date Receipt No Permit No. - nuande Date Mailed Delivered — <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Bo.2009 STOCKTON,CA Ill <br />