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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR'bFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY L <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 /> made in compliance with San Joaquin County Ordinan a No.1862 and the rules and regulations of the Sa Joaquin Local Health District. <br /> Exact Site Address 0 O S'— City/To, <br /> ity <br /> /Tow <br /> —ter �,... <br /> Owner's Name G O Phone / <br /> Address o t— S— <br /> City Gil Ham/ C'A4� a, C�. <br /> Contractor's Name L�ns24s� Business Phone.. �7 -- O 3 4 q <br /> Contractor's Address rgencyPhone FY 7—D <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ / <br /> REPLACEMENT❑ ` 1 <br /> DISTANCE TO NEAREST: Septic Tank/ d( = Sewer Lines L6 0 -4-- Pit Privy __ (!„ly <br /> Sewage Disposal Field_ �e� Cesspool/Seepage Pit,015� 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 /> ❑ DOM DTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> L+ MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing d2_ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal __ ffL_-_ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER O Pant Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: . C+ Q <br /> PUMP INSTALLATION: Contractor , 0 <br /> Type of Pump H.P. 1 <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 sons subject to workman's compensation laws of California." VVVJJJ <br /> will call for a Grout s c'o .pno to grouting and a final inspection. <br /> Signed Title: -1 Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO <br /> DEP IIENT USE ONLY <br /> PHASE [ <br /> Application Accepted By Date <br /> Additional Comments: :5�� <br /> lase 11 Grout Inspection Phase III Final Inspection <br /> Inspection Date -c Inspection By Date rw` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH .❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE U 06 �X"1 <br /> V <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date 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 20D9 STOCKTON,CA 9 <br />