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Applications Will Be Processed When Suh�e- operly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> _ PUMP&WELL � <br /> ENVIRONMENTAL HEALTH PERMIT 1 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY UI <br /> Application is hereby made to the San Joaquin Local Health District for a permit to coristruct and/or install the work herein described.This application is p(1 <br /> f made in compliance with San Joaquin County Or trance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town 37ng,!L�71 <br /> Owner's Name � Phone_ <br /> 93%11r 7_.i <br /> Address City <br /> Contractor's Name 12 u C-d License# 233 S�/ Business Phone -� <br /> Contractor's Address Emergency Phone 27-,d7-8v 7 <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 REPAII <br /> REPLACEMENT❑ �} <br /> DISTANCE TO NEAREST: Septic Tank r� Sewer Lines Pit Privy \ <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> i <br /> ,. Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> t ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> i DOMESTIC/PRIVATE ❑ DRILLED -Dia.-of Well Casing <br /> DOMESTIC/PUBLIC ' ❑ DRIVEN I Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK- Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION *: ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER :Other Information <br /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> fff PUMP INSTALLATION: Contractor <br /> ,Type of Pump -H.P. J�r <br /> PUMP REPLACEMENT: ❑ State Work Done,__. yn A-� /h ,.Zklne - _ <br /> [ PUMP REPAIR: © State Work Done <br /> DESTRUCTION OF WELL: ! Well Diameter �� Approximate Depth <br /> f t Describe Material and Procedure <br /> i1 <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 thework forwhich this permit <br /> is issued, I shall not employ an-y person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contacting signature certifies the followings"I certify that in the performance of the-work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> E I will call a ou p tion prior to grouting and a final inspection. G <br /> Signed X Title: l Date: 7 <br /> (Draw Plot Plan on Reverse Side <br /> r 1 <br /> I F DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By �""^ 2 Date -0/7 <br /> Additional Comments: ' <br /> Phase II Gr9ut'lnspect164 P ase III Final Ins ection <br /> Inspection By 1 Date Inspection By Date <br /> r <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT , lav PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REM#TTANCE $ REMIT <br /> BASE [EXPLANATION AMOUNT DUE CHECKED <br /> t DATE DATE REMITTED AMOUNT <br /> f _�FEE (7� <br /> LESS <br /> k PRORATION _ <br /> PLUS <br /> }- PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dater Receipt No. 'Permit No ssuance Date Mailed - Delivered Y* Y <br /> rFF � <br /> APPLICANT—RETURN ALL COPIES TO: .1 ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201' <br />