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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFLCE USE: APPLICATION A i <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&W,ELL :,* i Y <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ` <br /> Application 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._--�!A i <br /> made in compliance with San Joaquin County Ordinance No. 1862 and tate rules and regulations of the San Joaquin Local Health"bistrict. <br /> p �s <br /> Exact Site Address_;L.;1%(0 City/Town <br /> Owner's Name / '�.J1✓t�rvx-- Phone <br /> Address P t / U0 -- --- -- _� city <br /> Contractor's Name _ I <br /> License#����� Business Phone_ <br /> Contractor's Address do'cit Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance onIle With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONX 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 1 Private Domestic Well- Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL <br /> 11 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing i <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 Installed By: <br /> PUMP INSTALLATION: Contractor "'L 477, + _ } <br /> Type of Pump r _._. H.P. <br /> PUMP REPLACEMENT: __`--0-State Work Don '77"ta..M-.4 ; <br /> PUMP REPAIR: 11 State Work Dbne- - <br /> DESTRUCTION OF WELL: Re-11-Diameter, -Approximate_• Depth <br /> 11. .,,Y- ••,� F <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this applicatiAon 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. t1t <br /> Home owner 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 coM. pensation 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 /> 1� ) <br /> SI a for a Gr ut Inspection prior to grouting and-a final inspection. <br /> I 1.J <br /> . Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date 3a <br /> Additional Comments: <br /> Phase II Grout Inspection Ph" III Final Inspection <br /> Inspection By Date - Inspection By Date <br /> s, <br /> Fee Is Due: El ANNUALLY El PER UNIT El PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> l t _ REMIT <br /> BILLING REMITTANCE $ <br /> • - <br /> BASE, EXPLANATION - AMOUNT DUE CHECKED - t <br /> ' DATE DATE REMITTED; AMOUNT x <br /> i F <br /> FEE �Y _ •a"i <br /> LESS ` <br /> PRORATION <br /> PLUSH (� 1 <br /> PENALTY 70 <br /> Y) <br /> OTHER <br /> OTHER' <br /> Received by Date f Receipt No. Permit o. Issuance Date Mailed Deli ed <br /> - APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMITISERY10ES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 J <br />