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Applicatiohs Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> - .h (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE} ' =f AT-EIi- UAUTY os <br /> Application is hereby made to the SanJoaquinLocal-HbalthDistri t oraperml construct and/or install thework herein described.This application is I <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 Address/7"-,/-;A Y* � �� City/Town -,,�// <br /> Jj <br /> Owner's Name _ �' 11 ��` Phone -?,-,G ' <br /> Address '/;z% � i City <br /> Contractor's Name h S +� 5 License# 3c Business Phone '7 4✓tom_.=_/^+~✓-� <br /> Contractor's Address .--T c- 1 :j4 Emergency Phone `5AA _ <br /> Is Certificate of Workman's Compensation lnnsura.Sp on File With SJLHD Yes Z---' No <br /> TYPE OF WORK (CHECK): NEW WELL I=turDEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ; <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONZ;' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank/S Sewer Lines Pit Privy � 3 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property LindL,=__ Private Domestic Well ��_ Public Domestic Well = ' <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL_ ❑ CABLE TOOL Dia.of Well Excavation ! <br /> E?15'OMESTIC/PRIVATE ❑ DRILLED Dia`of Well Casing - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gat$96 of Casing / <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �cs <br /> f <br /> ❑ CATHODIC PROTECTION EI-110TARY Type of Grout °' l4 ' T <br /> ❑ DISPOSAL ❑ OTHER Other Lpformation__ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracto ' < <br /> Type of Pump + H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> - <br /> PUMP REPAIR: ❑ State Work Done - - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth C;. <br /> tA <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`i"I certify that in the performance of thework 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 thework for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California" <br /> will call for a Grout Inspection-prior-to-grouting and-a final.inspection.::7-' <br /> Signed} �� -��. _ Title: Com\ bat /0 <br /> fes. <br /> (Draw Plot Plan on Reverse Side)� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase-J41 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January.1 &Received By January 31 ❑ July t ti Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLSNG REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATEREMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> - -PENALTY <br /> OTHER <br /> OTHER <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 />