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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOIOFFICE USE: APPLICATION <br /> (For Non_Transferable, Revocable, Suspendable) �a <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , <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 ism <br /> I+ <br /> made in compliance with San Jaa uinC y Ordinance No. 1862 and the rules and regulations of the San Joapuin Local Fjealth District. " <br /> Exact Site Address <br /> j� 7 7 10A P11-f City/Town OG 4-V-ro � Coat_ <br /> Owner's Namey!�/,_ _,S . ��_.(�C_�} J4 Phone ZVKa, _" 21e/7 f <br /> Address City r <br /> Contractor's Na e L icense O PSl Business Phone -- d <br /> Contractor's Address ncy Phone >� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 2�-'DEEPEN ❑ RECONDITION 11DESTRUCTION❑ � <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _J_. Swer Lines.. — Pit Privy <br /> Sewage Disposal Field OCesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well �--�—* <br /> INTENDED USE TYPE OF WELL 1 �� <br /> ❑ IN_QUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing IV <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout S tl <br /> ❑ CATHODIC PROTECTION �iOTARY n Type of Grout -r—CZ MC o__\) <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed 6_: . �, lM e— 1W <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑-State Work Done R <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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:1 certify that in the performance of the work for which this permit i <br /> is issued, I shall not employ anyperson 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 'rsons subject to workman's compensation laws of California." <br /> a <br /> ill call for a Grout I sp t pri to routing and a final inspection. <br /> ! ��A �7 h <br /> Signed X i Title: _ Date: P <br /> ,r <br /> 1 (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout'Inspection Phase Ill final Inspection <br /> Inspection By I Date Inspection By Date ����d 2' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REWT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT i <br /> FEEy� <br /> LESS f <br /> PRORATION l <br /> PLUS > <br /> PENALTY <br /> OTHER F <br /> OTHER <br /> 21 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered- <br /> APPLICANT—RETURN <br /> elivered-APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -- 1501 E.HAZELTON AVE.,P.O.Box 2009 .STOCKTON,CA 95201 <br />