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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> [FOR OSFICE USE: ( <br /> APPLICATION <br /> (For Non-Transferable,Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> I <br /> (COMPLETE IN TRIPLICATE) �75;7(��E. Laur�� ,�.,/�fA_TER QUALITYAppl <br /> made in <br /> onishereby made tothe San JoaquinLocalHealth Districtforapermittoconstruct and/or install thework herein described.This application is ` <br /> made in compliance w1t Sa Joa pin Count Ordinanp No. 1862 and the rules and regulations f the San Joaquin Local Health District. <br /> Exact Site Address S VC, yt /Town Ckl <br /> Owner's Name C ( Phone <br /> Address = <br /> City 0.. <br /> Contractor's Name License# f/f�! Business Phone <br /> Contractor's Address f <br /> 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 ❑ <br /> REPLACEMENT PUMP REPAIR <br /> El <br /> DISTANCE TO NEAREST: <br /> Septic Tank J <br /> p �CZ-j~ _ Sewer Lines_ KO Pit Priv 1 <br /> Y <br /> Sewage Disposal Field (Z2t .._ Cesspool/Seepage Pit , <br /> Other <br /> f Property Line�� Private Domestic Well `s Public Domestic Well ----�` <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL +� <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> KDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �h <br /> ❑ IRRIGATIONW GRAVEL PACK Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> i ❑ DISPOSAL OTHER Other Information m <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter <br /> 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, <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a ro I spec rior to grouting and a final inspection. <br /> r _ <br /> Signed X I Title: Date: Z#A cq <br /> (Draw Plot Plan on Reverse S e) _T— <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By L�-/!dam Date/_34 z i <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCEg REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received'by Hate Receipt No. Permit No. I Issuan a Date Mailed Delivered r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bor 2009 STOCKTON,CA 95201 O <br />