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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR.OFF4CE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 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 Joaquin Local Health District. <br /> Exact Site,Address 40UJSiE1= MSKlkCity/Town —jC A773.0pop C.AL_l l -oreu to <br /> Owner's Name ©c c i d�r!i+A1 Ck-e „ca1 Cot.,ean.n✓ Phone — S I <br /> Address a •. sow 1 City Lrl zo e hi-rro13A/ A <br /> Contractor's Name J-, H. LG I rJ PC--spE AAS7& License# Business Phone CNig- i <br /> Contractor's Address;292_5- E fn gICT-tE S.-I-pr ?y A_3 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _c <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN El RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION F-1WELLABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ ! I <br /> DISTANCE TO NEAREST: Septic Tank i Sewer Lines Pit Privy j <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ` r, <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia, of Well Casing — Al f/� <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing , <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout daE�T G�r�r � <br /> ❑ DISPOSAL ❑ OTHER Other Information !+t <br /> GE9P++�`3heAL6"-Mr-4- %cpl t, I Surf ce Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. f <br /> PUMP REPLACEMENT: Q!State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 taws, 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will tail for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X K Title: Date: //!/ ��`'`�d <br /> I (Draw Plot Plan on Reverse Side) <br /> b .._fc <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE ] <br /> Application Accepted By - Date <br /> Additional Comments: <br /> Phase II Grout Inspection ase III Fi I Inspectlon� <br /> Inspection By Date Inspection Bim' .-r Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 y <br /> I REMIT I <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> f AMOUNT <br /> FEE 3 - -t{ <br /> LESS 6 <br /> PRORATION r <br /> PLUS L{ <br /> PENALTY <br /> OTHER f <br /> OTHER d +I <br /> o I 3 .3 la t Mn <br /> Received by Date u.t Receipt No. Permit No lAuancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r 4 r• <br />