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Appli0liiohs Will Be processed When Submitted Property CCinipleted. Be Sure I'd Sign The AhpHcallml. <br /> hDt'oF <br /> .,7-APPLICATION <br /> (For Non-Transferable, Revocable, Suapendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ;9 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal€the work herein described.This application is! <br /> made in compliance with San Joaquin County Or inance No. 18 2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address -� �L f rr T-�_.�! [ L. -_- City/Town <br /> Owner's Nam __ ___.___. _ Phone <br /> Address �7 _/City c5Q - <br /> Contractor's Name - �_� _ License fl. ,'!/L)?�C usiness Pho — <br /> Contractor's Address .-. 17 �. �(. ��-_ Emergency Phone <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 El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ___..., Pit Privy <br /> Sewage Disposal Field_ Cesspool/Seepage Pit Other <br /> r <br /> Property Line Private Domestic Well __.. Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ !>DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ---� <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of — <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ Ol"HEROther Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �U_Z_Z <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 , V <br /> ordinances, state laws, and rules and regulalions of the San Joaquin Local Ilenlih District. <br /> Home owner 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 shaft not employ any person in such manner as to become subject to workman's compensation laws of California." i <br /> Contractor's hiring or sub-contrecling signature certifies the following:1 certify that in the performance of the work lot which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c a Grout Inspects pri to groutiryg and a final inspection s <br /> Signed k _� `/�. ul �_ Title: _�../-'�-.�/` �L/_G/- _ _ --- Date: -- <br /> (Draw Plot Plan onreverse Side) <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE 1 -_ ` 6.� <br /> Application Accepted ByQ,�, �.J�� 1� - __ Date k0'a -�6V <br /> Additionai Comments: <br /> P�hase li Grout Inspection Ph III Final Inspectionection <br /> Inspec0on <br /> Date Inspection By ._ Dal I <br /> Fee Is Due: 11 ANNUALLY C3 PER UNIT ❑ PEI 51 f[ ❑ EAGIt ❑ Janriary 1 8 Neccivcd By January 31 ❑ July 1 &Raceived By July 31 <br /> BILLING -��—REMITTANCE _�—$�-- REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE, <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER rJ t > <br /> q � o 3C) . <br /> Received by pate � '" Receipt No. Permit No. 4ssu nca cardailed D©IivereN <br /> �- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Doi 2V9-n-,-STOCKTON,CA DS201 <br />