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Applications Will Be Processed When Submitted ProperlyCompleted. Be SureToSign TheApplication. �/ <br /> FOR Q.FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabie) I <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 Co my Ordinance No. 1852 and the rules and regulations of the San.Joaquin Local Health District. <br /> Exact Site Address I11 lnrl C', 14, City/Town <122 C7 1 <br /> Owner's Name —t�1 � _.!'1 L) Q. Phone <?-75 O <br /> Address Cityf? <br /> Contractor's Name o L4 14 in 144 i License# I3 Business Phone_4�� <br /> Contractor's Address So piki i Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No J <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION �— <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER Pk PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ _1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy r , <br /> Sewage Disposal Field . Cesspool/Seepage Pit Other <br /> Property Line Jit Private Domestic Well- Public Domestic Well <br /> a <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation—5/ Te_!i <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout M, <br /> ❑ DISPOSAL 94 OTHER Other Information <br /> ❑ GEOPHY44NNL Surface Seal Installed By: <br /> PUMP INSTA*TION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REP .--_ ❑ State Work Done <br /> STRUCTION OF WC-LA: Well Diameter Approximate Depth <br /> )r,e " jj De ribe Material a Procedure r/ i' c <br /> ` 1^Q 0� <br /> in IV o 4q 4 42 <br /> I hereby certify that 1 have prepared this application and that the work wi4 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 1he'lollowing:"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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 Will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: fJ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I cg <br /> Application Accepted By L� Date <br /> Additional Comments: An <br /> Phase it Grout Inspection Phase til Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT iy <br /> BASE EXPLANRTION DATE __-` DATE REMITTED AMOUNT DUE CHECKED <br /> f AMOUNT <br /> FEE { <br /> LESS <br /> PRORATION 41 <br /> PLUS <br /> PENALTY 11 <br /> OTHER i <br /> OTHER <br /> �� 6 S ! <br /> Received by I Date Receipt No, Permit No. Issuance Date Mailed Delivered <br /> APPLkCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.sox 2909 STOCKTON,CA 95201 <br />