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Applications Will Be Processed When Submitted Prop Irep ire y Completed. Be Sure To Sign The Application. <br /> 1009 OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) "I <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICATE € rr WATER QUALITY �� b—�/ <br /> ( ) l? O� S. .�f C I• NC <br /> Application is hereby made to the San Joaquin Local Health Distiiforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordirliance No. 1852 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address -4. f/6- (�C D �r//l�� uJ !2)City/Town �_/�"T ��' C A 4 (Fpm 1�1 <br /> Owner's Name GC ii Phone <br /> Address CityD L D <br /> Contractor's Name L S License# Business Phone <br /> Contractor's Address '2 2S J . JY\J2 �S _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT/L OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank " Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other��( 1/��T� <br /> Property Line . Private Domestic Well Public Domestic Well <br /> ti <br /> INTENDED USE TYPE OF WELL <br /> .I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE MDRILLED Dia. of Well Casing Q <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 /> SLC aGLjfN ICQ. Sur ace Seal Installed By: R a` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Puy tD <br /> PUMP REPLACEMENT: ❑ State Work Done { <br /> PUMP REPAIR: ❑ State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> DescribekMaterial 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 persoi in such manner as to become subject to workman's compensation laws of California." �f <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that ih 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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Sigued Xt.D�2I Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By " ' Date !�// <br /> ,I <br /> Additional Comments: <br /> Phase II Grout Inspection ase III Final s ection <br /> Inspection By Date Inspection B f Date <br /> Fee Is Dile: ❑ 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 DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> AL3 <br /> LESS <br /> PRORATION <br /> PLUS iI <br /> PENALTY 4 <br /> j <br /> OTHER <br /> OTHER , <br /> Received by ^'e Date Receipt No. Permit No. I suance to Mailed Delivered <br /> `APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E..HAZELTON AVE.,P.O.90:2009 STOCKTON,CA 95201 <br />