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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 /> I ENVIRONMENTAL HEALTH PERMIT j <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby-made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> y made in compliance with San.Joaquin County Ordina,j� e�No,1862 and the rules and regulations of the San Joaquin Local Heaith District. <br /> I Exact Site Address�ry /tf 77 ( ._. q City/Town l�j -CA.-_q c,_-2 <br /> c /JQ <br /> Owner's-Name A` b Phone <br /> Address — City 3 e <br /> Contractor's Namear •r D t <br /> �� � tJ,��'.� License#�� Business Phone <br /> Contractor's Address "'r ' v e -:'Emergency Phone r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW W J ❑ RECONDITION❑ DESTR6CTI01 "' 4 ' t <br /> I WELL CHLORINATION ❑ W L ABANDONMENT 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 1 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE-TOOL Dia. of Well Excavation <br /> 9�!�BLIC <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DRIVEN Gauge of Casing 1 <br /> ❑ IRRIGATION = n .❑ GRAVEL PACK Depth of Grout Seal <br /> a , <br /># ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout f <br /> t ❑ DISPOSAL ❑ OTHER Other Information i <br /> a 11 GEOPHYSICAL Surface Seal Installed By: r <br /> I PUMP INSTALLATION: <br /> It <br /> Type of Pump H.P. _ <br /> PUMP REPLACEMENT: - - ❑ State Work Done <br /> PUMP EPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: i Yell Diameter j� Approximate Depth <br /> Qr Describe Material and Procedure <br /> Ct CSfLt "� �qb 71 I <br /> I hereb 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work torwhich 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 will call for Grout spection prior t routing and a final inspectioJt <br /> Signed X _ Title: Date': <br /> (Draw Plot Plan on Reverse Side) ; <br /> FOR DEPARTMENT USE ONLY " <br /> PHASE I <br /> Application Accepted.l3 - _.. Date-� <br /> _a F . <br /> Additional Comments' <br /> Phase II Grout Inspection ase Final Inspection <br /> Inspection By Inspection $y.x Q Date `# <br /> Fee IS Due: ❑ ANNUALLY ❑`PER UNIT ❑ PER SITE ❑ EACH':; ❑ January 1-&Received By January 31 ❑ July 1 &Received By July 31 4 <br /> BILLING _ REMITTANCE: s - REMIT 4 <br /> • BASE EXPLANATION PATE DATE REMITTED' AMOUNT DUE CHECKED - I <br /> 00 AMOUNT <br /> FEE <br /> LESS . - T <br /> PRORATION t <br /> PLUS _ <br /> PENALTY s <br /> OTHER <br /> i F t <br /> OTHER <br /> Received by Date - _ Receipt No.� Permit No. - ,-. _J Issullince D to - Mailed- - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />