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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. /\t <br /> ,FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT l PUMP&WELL <br /> e <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework.herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Q0 City/Town G 'i <br /> Owner's Name KS W rS�_ _ Phone fs(o oL 7 OQ r <br /> Address AA City Zi?/�C.Y C � 3 <br /> Contractor's Name D License#,9,9�?d'� Business Phone — <br /> Contractor's Address F Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_A _ No i <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ <br /> REPLACEMENT❑ PUMP INSTALLATION 11 PUMP REPAIR❑ <br /> /g � <br /> DISTANCE TO NEAREST: Septic Tank (9 Sewer Lines Pit Privy <br /> Sewage Disposal Field ® Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well f <br /> INTENDED USE TYPE OF WELL r/ f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation �� J <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing to t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing A/-Q /j. <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout p F <br /> ❑ DISPOSAL ❑ OTHER Other Information 1 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: io P_ ja ile ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 30 r, <br /> tY = <br /> s 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t <br /> I will call ii Gr ut Insp ction pr' r to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 0 7 �y <br /> Application Accepted By , =/�/� <br /> Additional Comments: I <br /> e II Gro Inspection a III Fin nspectian <br /> Inspection-By Date Inspection By bate <br /> Fee is Due: ❑ ANNUALLY ❑ PEA UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 4, <br /> LESS <br /> PRORATION <br /> i' <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> 62---? <br /> Received by - Date Receipt No. Permit Np_ Issuance Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.'HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />