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Applications Will Be Processed When Submitted Properly Compieted._Be Sure To Sign The Application. <br /> ..FQR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> i (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Qrdinance//N!o. 1862 and the rules and regulations of the Sa oaquin Local Health District. <br /> t Exact Site Address City/Town x) <br /> Owner's Name � lee Phone <br /> Address R e G City 40 <br /> Contractor's Name A t License# Business Phone <br /> i <br /> Contractor's Address Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> r TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT*X OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I <br /> I' Sewage Disposal Field g Cesspool/Seepage Pit Other <br /> 1 Property Line 77.'�-7Private 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 V <br /> © DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> k DESTRUCTION OF WELL: `Well Diameter_ Approximate Depth <br /> F i Describe Material and Procedure XI Z L J,4//7-d CiDA/C O c ITIE. <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 /> r 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 a loy persons subject to workman's compensation laws of California." <br /> i <br /> f I 1116call for a Gr I s ction prior to grouting and a final inspection. 1 <br /> Signed X Title: Date: — ( � <br /> (Draw Plot Plan on erse de) <br /> FOR.DEPARTMENT USE ONLY <br /> PHASE I <br /> i <br /> Application Accepted By Date 3 a u JI <br /> i Additional Comments: t; <br /> Phase II Grout Inspection PRase 111 Final Inspection + <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 eived By January"31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED f <br /> i� DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS L <br /> f PRORATION <br /> PLUS <br /> PENALTY <br />` OTHER <br /> t <br /> A <br /> OTHER' <br /> 713/ <br /> �ll� _- /moo � <br /> Received by ate Receipt No. Permit No. Issn Date Mailed Delivered <br /> q APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16DL E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />