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Applications Will Be Processed When Submitted Properly Completed. Be-SureToSignTheApplication. <br /> �� <br /> FOR OFFICE USE: <br /> APPLICATION --� <br /> L (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Y <br /> (COMPLETE IN TRIPLICATE) <br /> WATER.:L Y <br /> Appl ication-is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Jo a uin County Ord'nanc N 1862 and the u es and regulations of the Sa qui�Lo al Hea h District. <br /> ' Exact Site Address,�9� Q� �• A#?A 'aS� �' City/Town c�`► <br /> ! Owner's Name J L-A Z Phone Ci Address d S • 16101 <br /> !JN City atJ-���,2� <br /> Contractor's Name LL DR �� nse# �,� Businesshone_ f <br /> Contractor's Address .& #4-V Emergency Phone JJ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YeNo <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ j� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 5 + Pit Privy <br /> Sewage Disposal ,F,i�eld ns1� Cesspool/�Seepage Pit LK t <br /> her <br /> Property Line_.Z__Private Domestic Well_N Public Domestic Well <br /> Ovar <br /> k INTENDED USE ; TYPE OF WELL ZS� <br /> ❑ INDUSTRIAL i ❑ CABLE TOOL Dia. of Well Excavation •. <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing // d <br /> i ❑ DOMESTIC/PUBLIC ,❑,.DRIVEN Gauge of Casing <br /> ❑ IRRIGATION )p GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION j ROTARY Type of Grout C m NT <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ 1V+r_rd lit. <br /> GEOPHYSICAL I y Surface Seal Installed By: �� <br /> PUMP INSTALLATION: Contractor S <br /> Type of Pump Su — H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I. PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> I <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 /> I Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> t is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> S Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will I for a Gr ut lnspec' n pri to grotlIliting and a nal inspec f V <br /> SigneTitle: Date: <br /> d X <br /> + (Draw Plot Plan on Reverse Side) <br /> R DEPARTMENT USE ONLY +. <br /> PHASE I <br /> Application Accepted By Dat <br /> I Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> R <br /> # en <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 /> BILLING REMITTANCE' $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> .� DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 4' <br /> I OTHER <br /> OTHER <br /> _Permit No. - Issuance Date Mailed Delivered <br /> Received by Date I Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMITlSERYICES 1601,E.HAZELTON AVE.,P.O.Sox 2009 . STOCKTON,CA 95201• <br />