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Applications Will Be Processed When Submitted Properly Completed.-fie Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) 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 is ti <br /> made in compliance with San Joaquin C`ounty OW! ante No. 1862 an the rules and r ations of the San Joaquin Local Health District. <br /> A <br /> Exact Site Address f�� l� /'[/L/�._&M ✓e City/Town I• ____ <br /> Owner's Name Iop e Phone <br /> Address 0 G`(��/C—' P City. C1 c , <br /> 'Contractor's Name v Ch ' 1;/ License#--YW 3 Business Phone (i�_� 14 7 _ f <br /> Contractor's Address.J_A10^p Al' eq^pPhone /UdAJ"0-- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL© DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 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 <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 0 DRILLED Dia. of Well Casing — r <br /> 0 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 0 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 0 GEOPHYSICAL /surface Seal Installe <br /> PUMP INSTALLATION: Contractor !L ✓I [ Ce <br /> Type of Pump H.P. <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 /> 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 'll call for a Grout I pection Rrior to grouting and a final inspection. <br /> Signed X Title: 4� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI f j <br /> Application Accepted By- ' —�J Date / <br /> Additional Comments: <br /> PhasgAl Grout Inspection P e III f=inal inspection <br /> Inspection By Date Insr7rkpection By Date <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 $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION 1� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Datd Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />