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Acatlons Will Be Processed When Submitted Properly;Compleled. Be Sure To Sign The Application, <br /> ~" (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL � •:� <br /> -ENVIRONMENTAL`HEALTH PERMIT _ <br /> ,JIPLETE IN TRIPLICATE) { WATER QUALITY ( J <br /> ��,pplication is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San oaquin County Ordirisnce No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> xact Site Address ZL� �• usY � City/Town 1 77 <br /> .�Owner's <br /> Name 2 a r�Phone - S <br /> Address � City <br /> Contractor's Name ' cense <br /> ,ytrZe �j(���/ frY�7?//� Business PhoneS�l /L7 <br /> Contractor's Address l� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X- . No <br /> TYPE OF WORK (CHECK): NEW WELLI}- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL,ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic TankA26 Sewer Lines Pit Privy <br /> Sewage Disposal Field e4 Cesspool/Seepage Pit Other <br /> Property Line/e:2-* Private Domestic Well_�� Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL k0 CABLE TOOL Dia. of Well Excavation /-z _. - <br /> AQ DOMESTIC/PRIVATE © DRILLED Dia, of Well Casing r� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ <br /> +" ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> f ❑ CATHOD-IC PROTECTION ROTARY Type of Grout - <br /> ❑ DISPOSAL ❑ OTHER Other Information Q <br /> ❑GEOPHYSICAL Surface Seal Installed By: V <br /> PUMP INSTALLATION: Contractor <br /> .Type of Pump H.P. <br /> PUMP REPLACEMENT: I''30 State Work Done <br /> PUMP REPAIR: ❑ State Work Dane <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 forwhich this <br /> r permit is issued, I.shall a ploy per ns subject to workman's compensation laws of California." <br /> I wi call for a out ect' for to grouting and a final inspection. t <br /> 77 44, <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Revers ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I P 0 <br /> Application Accepted By Date <br /> Additional Comments: <br /> has rout Inspectiont �3 7 Phase 111 Final Inspection <br /> Inspection By Date ZInspection By Date <br /> �k �cr <br /> Fee IS Dile: El ANNUALLY ❑ PER UNIT .. la PER SITE ❑ EACH ❑ Sanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> + BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 1 DATE DATE REMITTED AMOUNT <br /> ` FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> �s <br /> f OTHER <br /> OTHER -- <br /> -------------- <br /> Received bye"'' -�-�.- Date Receipt No. ,_1 Permit No.- a, - Ys uance Date Mailed - Delivered <br /> ..4 . <br /> APPLICANT—RETURN ALL COPIES TO:�ENVIRONMENTAL-HEALTH`.PERMITISERVICES _ 1601 E:HA2'ELTON AVE.,P.O.Box 2009 .STOCKTON,CA 95201 <br />