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'� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. k <br /> ",FFICE uSE: APPLICATION <br /> (For NonyTransferable,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 for a permit to construct and/or install the work herein described.This application is <br /> ode in compliance wit/h Sany uin County Ordinance No. 1862 and the r/�les and regulations of the Sag Joaquin al Zalth �t � <br /> r Exact Site Address / •✓ �a� /Sc0 City/Town L f© <br /> i <br /> Owner's Name /n Phone Z-�f0 <br /> Address City <br /> Contractor's Namea License# Business Phone s� <br /> Contractor's Address Emergency Phone _?TT <br /> _.�Z Jr6 4 <br /> Is Certificate of Workman's Compensation 20"' <br /> st0 n o ile I %,ftHD? Yes No OQ <br /> TYPE OF WORK (CHECK): NEW WELL I� DEEPEN ❑ RECONDITION❑ DESTRUCTIl2N❑ �J <br /> WILL 0Ig0Mh% YZA1 ra OiFi��?f�fA'S's'`A'p+t���,2 r3-TWF-D.11 ni MAD inicTAi 1 AT1nNl � of Inco or=onloi-1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 140ft Pit Privy -- r <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 ► I ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ,❑.,/DRIVEN Gauge of Casing <br /> ❑ IRRIGATION to GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY _Type of Grout ffAz< 657a047' <br /> ❑ DISPOSAL ❑ OTHER Cher In " Pnaf <br /> ❑ GEOPHYSICAL:-- � Surface Seal Instal�By <br /> UMP INSTALLATION Contracto � � <br /> �— - Type of Pu H-P. <br /> PUMP REPLACEMENT: ,tate Work Done <br /> PUMP REPAIR: —i O,State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -S <br /> t Describe Material and Procedure O <br /> T7 D <br /> l hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ft ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <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 /> s <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 persons subject to workman's compensation laws of California." L) f h <br /> I will al r a Al out pe n prior to utin and a final inspection. kv')1Tf/ <br /> x Signed X s� u' itle: Date: � z <br /> (Draw Plot Plan on Reverse Side) I <br /> r <br /> r _ FOR DEPARTMENT USE ONLY ' <br /> PHASE I �} /� � Dat <br /> � <br /> Application Accepted By ,.A <br /> Additional Comments: w <br /> Phas II Grout Inspection se I Final Inspection <br /> Inspection By Date Inspection By Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UWT ❑ PER SITE ❑ EACH ❑ January 1 &Received'By January 31 ❑ July 1 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE LF <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> t� <br /> OTHER y <br /> OTHER <br /> Received by D eI Receipt No. Permit NO" Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />