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Applications Will Be Processed When Submitted Properly Completod. Be Sure To Sign The Application. <br /> FOR OFFICE USE: C�,�J„�� APPLICATLON_ ; <br /> (For Non-Transierable, Revocable, Sue;pendable) <br /> � <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY X <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County rdin nce No. 1862 and the rules and regulations of the San Joaquin Loc I ealth District. <br /> Exact Site Address S d�6 6 JG4% & � &2 _ City/Town A <br /> Owner's Name 14 ee `G tow Phone <br /> Address tio 16 04dkJ&W City <br /> Contractor's Name L a License# 93 72,1 Business Phone me —7,(.:7 L <br /> Contractor's Address A 54 ' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With S LHD? Yes--X No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation _1t� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing __ - r <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 Surface Seal Instal d By: <br /> PUMP INSTALLATION: Contractor � "C+ <br /> Type of Pump cl 4 g:? H.P. / <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done rboD d t� (Z46✓ glitge 1 <br /> DESTRUCTION OF WELL: Well Diameter 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for aGrout Inspec pri r gro ting and a final inspection. <br /> Signed X itle: t+ f Date: /a <br /> (Draw Plo Ian on Reverse Side) <br /> F EPA TMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date G <br /> Additional Comments: / <br /> Phse II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By kft AIL Dateb 1�7Q <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLENG REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE S, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER pp g2l f A (f <br /> lot i o b <br /> Received by - Date Receipt No, Permit No Issulince D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />