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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT f -� /0 -Tr3 <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 <br /> P <br /> made in compliance withSanJoaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /��l g �e r/.fc.P�� City/Town <br /> Owner's Name ,: (P�,L—�:.. Phonea`� _X_6PU.3 <br /> Address S �=_� c O .1: . r- City _ h <br /> Contractor's Name License#z7TrY—) 1 Business Phone S "� <br /> �t %. 3 <br /> Contractor's Address U Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No 7 <br /> TYPE OF WORK (CHECK):" NEW WELL.0 <br /> - DEEPEN ❑ RECONDITION❑- DESTRUCTION,❑ -WELL CHLORINATION WELL ABANDONMENT ❑ OTHER ❑ :PUMP INSTALLATION fid' PUMP REPAIR❑ <br /> REPLACEi LENT❑— <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> i Sewage Disposal Field. Cesspool/Seepage.Pit Other <br /> r Property Line Private Domestic Well Public Domestic Well <br /> _ INTENDED USE TYPE OF WELL <br /> C alltsIDU§TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> dtd DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK. Ty-Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �--z- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _.4..[.C. - _.._ 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 C <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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X _G `�-+ Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By _ Date <br /> Additional Comments: I <br /> Phase II Grout Inspection Phas II Final Inspection <br /> Inspection By I Date Inspection By {� Date <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January T&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE -EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE. REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS , <br /> .PENALTY <br /> OTHER r. , _+ <br /> OTHER <br /> 9-1 <br /> Received by Date „ Receipt No. Permit,No. ss ante Dae Mailed Delivered „ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21)09 STOCKTON,CA 95201 <br />