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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) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPUTE 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 witti San Joa in CouVtyprdinance No. 1862 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address !L City/Town G A/ <br /> Owner's Name C9 Phone yl y 3 <br /> Address ik"A—S f' ` City � A," C"Q. —•���-� <br /> Contractor's Name7 V <br /> P license#� �� Business Phone 7 e�1 B <br /> Contractor's Addressy Emergency Phone g / 7^^ 63g 7r <br /> Is Certificate of Workman's Compensation I,n�,surar on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLW- DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Q� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank C)( Sewer Lines /'D d I"��- Pit Privy <br /> Sewage Disposal Field e 6 f .f— Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well r----- Public Domestic Well <br /> INTENDED USE TYPE OF WELL / tr <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 9 OMEST1C/PRIVATE ❑ DRILLED Dia. of Well Casing Ce5,,��� �. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> -- <br /> ❑ IRRIGATION ❑ GVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION L�ROTARY Type of Grout <br /> � DISPOSAL 1:1 OTHER Other Information <br /> L� <br /> © GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor y <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 <br /> Describe Material and Procedure <br /> 1 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 /> ermit is issued, I shall emplo sons subject to workman's compensation laws of California." <br /> 11 call for a Grout ns c n 'o to grouting and a final inspection. Ml <br /> Signe f Title: - ^��,._`� r,� " tate: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I �d <br /> Application Accepted By Date <br /> Additional Comments: <br /> S <br /> Phase H Grout Inspection Ph a III Final Inspection <br /> Inspection By Date Inspection 13y Date ` d <br /> El UNIT PER SITE ❑ EACH ❑ January l &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY4 <br /> REMIT E <br /> BASE EXPLANATION BIL ING REMITTANCE $ 1 <br /> DATE DATE REMITTED AMOUNT DUE CHECKED li <br /> AMOUNT <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 1 <br /> OTHER <br /> I <br /> '.Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> '..APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1641 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />