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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION _ <br /> (Por Non-Transferable, Revocable,Suspendable) / <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)7g'Ov sy W 0 LF£ WATER•QUALITY 6 <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County 0{diinance No. 1862 and the rules and regulations of the San Joaq 'n H�h District, <br /> Exact Site Address dI I>;sJEaT. 81r t#'t�%)*Rz ROr4D City/Town " ~ <br /> Owner's Name LG1 ��1V Phone <br /> Address ,5 • 1 4 City L-* <br /> Contractor's Name License#" Busin ss Phone— Li <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insypome on File kth SJLHD? Yes tw0000* 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 /> Sewager0isposal Field Cesspool/Seepage Pit Other-. <br /> Property Line Private Domestic Well Publ� i]�`Xriestic Well `< " ` <br /> INTENDED USE �- ,� TYPE OF WELL <br /> ❑ INDUSTRIAL ''s. ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑'DRILLED Dia. of Well Casing I <br /> ❑ pOME STIC/PUBLIC 13 DRIVEN Gauge of Casing <br /> IRRIGATION =t ❑ Q2AVEL,.PACK ; Depth of GFout Seal ~�~ <br /> ' ❑ CATHODIC PROTECTION Q/ROTARY N, ype of Grout <br /> ❑ DISPOSAL P ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r ., Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor' s �T ? <br /> Type of PumpL� H.P. <br /> PUMP REPLACEMENT: C1State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 3 Approximate Depth <br /> Describe Material and Procedure 41 <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 /> Home owner or licensed agent's signature certifies the following:"I certify that.in the performance of the work for which this permit r„- <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Co tractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> peit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wl call for a Gr u nsp ti prior grouting and a final insp tion. <br /> Signed X Title: C.1 Date: �*l� &2, <br /> (Draw Plot Plan on Reverse Side) d <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By v� �U�" '' Date l <br /> Additional Comments: <br /> Phase II Grout Inspection P a III Final spection <br /> Inspection By Date Inspection By w ate +�p���•�^ <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 .y;•^ p AMOUNT DUE CHECKED <br /> DATE DATE _ r-REMITTED AMOUNT <br /> f - <br /> p FEE <br /> 4 LESS <br /> PRORATION 2 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .l L4 I � gv <br /> Received by Date Receipt No Permit No. ssuaned 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 />