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Applications Will Be1rocessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> )R OFFICE USE: - APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ! <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 theworkherein described,This applicationis U <br /> made in compliance with San Joaquin County Or finance No. 1862 and the rules and regulations of the San Joaquin Local Health District. NJ <br /> Exact Site Address j City/Town <br /> SE 4— <br /> Owner's Name 927AZ [c-a e-S' Phone 9s, <br /> Address City FA211 , <br /> Contractor's Name icense#.-?4 4f f Z Business Phone -a6 <br /> Contractor's Address Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 y <br /> REPLACEMENT, <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property tine Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <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 Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: A State Work Done, /_&e? .j�4: z &Z, _z ��a fu <br /> PUMP REPAIR: ❑ State Work Done_ <br /> fir_-- �. <br /> DESTRUCTION OF WELL: Well Diameter T '� Appr-oximate 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 /> Home owner 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 /> 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 will call forf /a Grout Inspection prior to grouting and a final.inspection. r ` q <br /> Signed X � e.�l�� . L Title: C-�71Lf%r�c e7^� Date: v2 5 1 <br /> i (Draw Plot Plan on Reverse Side) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ _ _ _ `f <br /> Application Accepted By ` y - Date <br /> Additional Comments: <br /> Phase II Grout Inspection -PhazXl.11 Final Inspection <br /> Inspection fay Date Inspection By to )�' 7 <br /> ZZ 9 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ duly 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE. 5 <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> L - OTHER <br /> OTHER <br /> i i•��p <br /> —7q—►-337 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 />