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Applications WilliBe Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> + w. (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> I 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 County Ordiniance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address L)1!5,- A llicf E +_ City/Town /_>-"�geo 4 C L Xop_N fig <br /> Owner's Name 0 E Phone <br /> Address a o city C. 1!1: i/ P C,44/r=a,e N/A <br /> Contractor's Name 2-- LC- 1J EGr, License# Business Phone4¢Lg <br /> I Contractor's Address 2is:cE— U�TL6 57z�r_.K_"0.- 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 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well :T--- 1 +rte <br /> INTENDED USE TYPE OF WELL r I <br /> t ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation— <br /> � C <br /> ❑ DOMESTIC/PRIVATE R?I DRILLED Dia. of Well Casing Al ii <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing N/li <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> �F ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout FAT 0r7'�'t E-iu7- <br /> ❑ DISPOSAL ❑ OTHER Other lnforrnation �~ <br /> Q GEOPHymc7rL 6Ea7r-cff d 1CAc- Surface Seal Installed By: -� <br /> PUMP INSTALLATION: Contractor 1 T <br /> Type of Pump H.P. <br /> F PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r <br /> Describe Material and Procedure t <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 /> t Contractor's hiring or sub-contracting signature certifies the following:"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 /> I will call for a Grout Inspection prior to gi outing and a final inspection. <br /> Signed X 3 /.S 5 Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEIf �Q <br /> Application Accepted By `f Date <br /> Additional Comments: <br /> Phase 11 Grout inspection 6�� aseFal Inspection <br /> Inspection By Date Inspection B Date L <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED { AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER /- <br /> OTHER <br /> Received by Date Receipt No. Permit No - Issiatince Dae Mailed Delivered <br /> APPLICANT—RETURN ALL,COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.NAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />