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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR.OPFtCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto 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 Np.,1862 and the rules and regulations of the Saquin cal Health Di ict. <br /> Exact Site Address � �a IrU City/Town V ' <br /> Owner's Name Phone <br /> Address city1 <br /> Contractor's Name License# 275'1 Business Phone <br /> Contractor's Address CAlfmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Com' No jyp <br /> TYPE OF WORK (CHECK): NEW WELL®-_ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 3 Ot7� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Z"PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit 9/`e-le— Other �--� <br /> Property Line — Private Domestic Well ----+ Public Domestic Well <br /> INTENDED USE TYPE OF WELL / <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation � <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing g r <br /> [&'ffO—MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 4 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 2+ OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:fM <br /> PUMP INSTALLATION: Contractorr/_.� �.__.� S r %A,e C-- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done C' <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 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work fpr which this <br /> >SZ�o <br /> mit is issued, I shall employ per on subject to workman's compensation laws of California."r <br /> ll call fr a Grout I s p r to routing and a final inspection. /� <br /> SiTitle: (S a�A—a C 1r 1E1�� _ Date: <br /> 1 (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> HASE.I _ ] <br /> Application Accepted By � Date ` T-Urn <br /> Additional Comments: <br /> P as II Grout Inspection Pha a III Final Inspection_/ s <br /> Inspection By v <br /> Date NQ -^11 Inspection By `� Date "1(yl`-1?L <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &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 l <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERCAD <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 AYE.,P.O.Box 2002 STOCKTON,CA 95201 <br />