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f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. ,e— <br /> 1 FOR OFFICE USE: APPLICATION k K <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> i Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Jopt uinCLo Local District. <br /> Exact Site Address L �-+ Mehr City/Town 5 Q <br /> Owner's Name "Doo �6 8 .to -- Phone _qlag-- �16r1 (WO_k4 <br /> Address t VIOL City 61M <br /> Contractor's Name %AxiiAr i+ Q 1. License# IJP Business Phone <br /> Contractor's Address �A _���� 'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L/ No <br /> TYPE OF WORK (CHECK): NEW WELL�L DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ppp��� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENTr <br /> DISTANCE TO NEAREST: Septic Tank too,+ Sewer Lines Pit Privy (� <br /> Sewage Disposal Feld Cesspool/Seepage Pit Other }� <br /> 4 <br /> Property One Private Domestic Well Public Domestic Well <br /> INDUST=RIAL ._ �,. __.s :.� . ..- <br /> INTENDED USL TYPE.OF WELL, - r' r <br /> ❑w .[1CABLE-TOOL .:_1]ia. of WeII,Excavation...., .,- _---- <br /> t DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing ®�f <br /> k El DOMESTIC/PUBLIC © DRIVEN Gauge of Casing <br /> ❑ IRRIGATION i* ❑ GRAVEL PACK Depth of Grout Seal �d <br /> Y-_r�. <br /> ❑ CATHODIC PROTECTION � ��ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> <aw <br /> M <br /> ❑ GEOPHYSICAL 4` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f ❑ State0ork-Done --- — s <br /> PUMP REPAIR: ❑ State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth - A <br /> Describe Material and Procedure _ f <br /> . _ <br /> I hereby certify that I have prepared this application Vand that the work will b+e 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 /> i <br /> is issued, I°shafl'not employ any person`•in such manner as to become subjecbto workman's compensation laws of California." <br /> ACtractor's hiring orsub-contracting signature certifies the following:"I certifythatin the performanceof the work for which this <br /> is issued,' shall employ personssubfecfto workman-scompensatiU-n jaws of California." <br /> all fora ou Insp i prior t routing and a final ins coon <br /> Signed .d fX '`�Title: Date: <br /> (Draw•P.Lct Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i17 <br /> Application Accepted By— Date cti _ <br /> Additional Comments: I <br /> Phase II Gr I spectlon Phase 111 Final Inspection, <br /> Inspection By7_._��r- -Ar4Date �` 6� Inspection By iyA Date # <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &;Received By July 31 <br /> �� BILLING REMITTANCE $ REMIT <br /> ,BASE :1 EXPLANATION PATE DATE REMITTED <br /> MOUNT DUE CHECKED <br /> tttttt AMOUNT <br /> FEES <br /> LESS I <br /> i PRORATION <br /> PLUS _ <br /> { PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date Receipt No. Permit No, Issuan a Dat6 Mailed Delivered <br /> r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITtsERVICES;. 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201_ <br />