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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> nh oFrACE USE: APPLICATION 7/ e ` <br /> (For Non-Transferable, Revocable,Suspendabie) PUMP&WELL v <br /> ENVIRONMENTAL HEALTH PERMITJ" <br /> (COMPLETE IN TRIPLICATE} ` WATER QUALITY D tr— O So^D 2- <br /> .pplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with Sa,,n�lJoaquin County/Ordinance No. 1862 and the rulesandre,}ulationss of the San Joaquin Local Health District. <br /> Exact SiteAdd ress,a /4/dIAt 6f_ h,w,d �� ec��o.�. �. lllal�[ VIS g2 y/Town �6 <br /> Owner's"Name +?�E2 ./IK�i4t/►aE.ut< /t�I one <br /> Address tl'f City a <br /> Contractor's Name -f- ' "License#,n?// (K Business Phone_ <br /> Contractor's Address ,, ;, Emergency Phone <br /> is Certificate of Workman's Compensation insurance on File With SJLHD? Yes X No J <br /> TYPE OF WORK (CHECK): ' -NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines t5-0 Pit Privy -- -_. <br /> SewageE Disposal Feld //?6 14 Cesspool/Seepage Pit Other <br /> Property Line /0 4- Private Domestic Well <O -t~ Public Domestic Well <br /> INTENDED USE z TYPE OF WELL ,t <br /> ❑ INDUSTRIAL k CABLE TOOL Dia. of Well Excavation— <br /> El <br /> xcavation❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ' <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r�. <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout (A) <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL .Surface Seal Installed By: 0u9AI49 <br /> PUMP INSTALLATION: I Contractor <br /> Type'of Pump H.P. <br /> PUMP REPLACEMENT: t ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 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 the work for which this k <br /> permit is issued, I shall erriploy' er ns subject to workman's compensation laws of California.— <br /> 'or <br /> w' all �utpecti for to grouting and a final inspection. / <br /> Signed X Title: Ww,7Lk Date: <br /> (Draw Plot Plan on Revers ide) I <br /> - f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ^�u <br /> Application Accepted By - ' .Date C <br /> ^a` <br /> Additional Comments: I <br /> Phase II Grout Inspection t Phase III Final Inspection <br /> Inspection By Date Inspection By Date t <br /> Fee IS Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED, """AMOUNT DUE CHECKEDAMOUNT <br /> L <br /> i k I <br /> FEE <br /> Oct <br /> LESS <br /> PRORATION <br /> PLUS - •, <br /> PENALTY <br /> OTHER <br /> a <br /> J <br /> OTHER '' - ! <br /> Received by Date Receipt No.- Permit No. tissuance bate Mailed- t Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />