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= Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION l' <br /> FOR OFFICE USE: � •` �1 <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> �-� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application*herebymadetothe San Joaquin Local Health Districtforapermittoconstruct and/or install the work herein described.This application is � <br /> made in coMoianCi3-_ it6 San-Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health Distract. <br /> Exact Site Address --,S �' �'C.-Ok � City/Town <br /> +. <br /> Phone V� <br /> Owner's Name �� `Y OT <br /> City <br /> Address 7 �5 'C`�ti acti GG`' <br /> License# ycse 3_ Business Phone 1`r5 <br /> Contractor's Name ' <br /> Contractor's Address' CuZ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �( <br /> TYPE OF WORK (CHECK): NEW WELL14 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ �3 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Li es Pit Privy i <br /> Sewage Disposal Field ` O Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well y <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL , Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 V6 <br /> 4 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing SicVOC <br /> ❑ IRRIGATION ® GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grouta:�` � � <br /> SIL <br /> 11DISPOSAL 11OTHER Other Information - <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor ._.. <br /> H.P. <br /> Type of Pump _ <br /> PUMP REPLACEMENT: ❑ 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 /> Home owner 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 /> t 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 a Grout Inspection prior to grouting and a final inspection. r� <br /> f Signed X c Title:�l/A,z4 f °r1�.gl.r�'�'��„' Date: 4 <br /> raw Plot Plan on Reverse Side) <br /> + FOR DEPARTMENT USE ONLY <br /> PHASE 1 Dat <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout inspectionPh IIIFinal Inspection r�Z <br /> Inspection By Date SI-7—,c .k— inspection By Date d <br /> Fee IS DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH ❑ January 1 R Received By January 31 July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATIONS BILLING REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ! FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> F <br /> Received by <br /> Dat Receipt No. Permit No. Issuance 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 />