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ApplicationsWill BeProcessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> e-0 tx /c,4 (For Non-Transferable, Revocable,Suspendable), <br /> } ENVIRONMENTAL HEALTH PERMIT / PUMP&WELL <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 <br /> made in compliance With San Joaquin County.Ordinance No. 1862 d the rules and.reguJations of the San Joaq n Local Health District. <br /> Exact Site Address q6.3 MQr/ o <br /> 1_ _,_ City/Town / <br /> Owner's Name i1�.S�' L104< *ar h oS Phone <br /> Address -+D. 16.0X. 7Y City rt <br /> cSv4� a <br /> Contractor's Name a 69 Zo License#4_A_-7_14, Business Phone_ �3� "� le i <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File h SJLHD? Yes t, No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION J91 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 Private'Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <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 , OA- <br /> Type of Pump -.H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP AIEPAI : QI State Work Done AV q„1 <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 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 /> 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 wi call for a Grout Inspect on nIr t grou ' g andfinal inspection. <br /> Signed -Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase11 Grout Inspection Phase III Final Inspection <br /> Inspection By— A 6� Date Inspection By --- Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 eived By January 31 ❑ July 1 &Received By July 31 <br /> BILLINGREMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE DC7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. Issuanc Date J Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />