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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with Joa in C ty Ordinance No. 1862 and the rules and r ul tions of the San Joaquin Lof�aI Health District. <br /> Exact Site Address City/Town �j C.. a, <br /> Owner's Name `. Y Phone <br /> Address ' City <br /> Contractor's Name 1,44'4�9 C C. License#�CLQ Business Phone_y,61:�1 f 2 <br /> Contractor's Address ���G�c 5tD a t2 Emergency Phone S!E u" ` <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❑ f " <br /> DISTANCE TO NEAREST: Septic Tank __,/a O Sewer Lines Pit Privy t\ <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> W <br /> Property Lirie Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ` /r <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Weil Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ <br /> 1❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Po a <br /> ❑ CATHODIC PROTECTION If ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ <br /> GEOPHYSICAL, Purface Seal Installed By: mi.c 1 D--It <br /> PUMP INSTALLATION: Contractor W/,Z <br /> Type of Pump -u H.P. [} <br /> PUMP REPLACEMENT: ❑ State Work Done `VR} <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 <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 thet 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 /> I will ca ora rout Inspectlo r to utin d a final inspection. / <br /> Signed Title: c-✓ _ Date: . <br /> (Draw Plot Plan on Reverse Side) <br /> t - <br /> o t FOR DEPARTMENT USE ONLY <br /> PHASE I4M <br /> Application Accepted By a/ l r0.— -- , Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection �IFinal Inspection <br /> Inspection By Date Inspectipn By Date I r rZ <br /> Fee Is Due: ❑ ANNUALLY ❑MPER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 & eived By January 31 ❑ July 1 &Received By July 31 <br /> I BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> i AMOUNT <br /> FEE q �" _ <br /> LESS .E <br /> PRORATION - ' Al <br /> PLUS - <br /> PENALTY ' <br /> tr a3 e: a <br /> OTHER <br /> OTHER 2 <br /> I 3 /ykI - <br /> n Reteived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />