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—Applications Will Be Processed When Submitted-Properly Completed. Be Sure To Sign The Application. <br />' %FoR OFFICE USE: APPLICATION <br /> ca fa ' (For Non-Transferable, Revocable, Suspendable) <br /> ov PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I Application is hereby made to the San Joaquin Local Health Distridtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with _&San Joaquin Co ty'Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. r <br /> Exact Site Address ;_111— 41 Laaii� Zxyl 4J eh N.1s.al 4_4 City/Town <br /> I Owner's Name 77 Phone i <br /> I Address City <br />�. <br /> Contractor's Name G1' License#hf-477J Business Phone Q r <br /> Contractor's Address Emergency Phone t4` <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes �C___ No <br /> EEPEN ' <br /> TYPE OF WORK (CHECK): NEW WELL❑ D ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONAI 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 <br /> INTENDED USE TYPE OF WELL t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN., Gauge of Casing • <br /> ❑ IRRIGATION ❑ GRAVEL PACK F Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY t Type of Grout <br /> ❑ DISPOSAL ❑ OTHER x Other Information <br /> ❑ GEOPHYSICAL i SurfaSeal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_ j H.P. S N <br /> I PUMP REPLACEMENT: II State Work Done e <br /> i PUMP REPAIR: ❑ State Work Done Z_ <br /> DESTRUCTION OF WELL: Well Diameter b Approximate Depth <br /> Describe Material and Procedure �{ <br /> 3 <br /> I � � <br /> 1-trereby 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 <br /> is issued, I shall not employ any person in such manner as ta'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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws'of California." <br />,. I ill call for a Grout Insp c I pr to grputi and a final inspection. \� ' <br /> Signe tle: /�s✓' Date: " \ <br /> (Draw PE P anon Reverse Side) <br />` <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> l <br /> Application Accepted By Date <br /> S Additional Comments: <br /> 1 <br /> Phase II Grout inspection Phase III Final inspection <br /> i Inspection By Date Inspection By Date <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED i} <br /> AMOUNT <br /> a <br /> a <br /> FEE Com_ c <br /> LESS v <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER d <br /> OTHER <br /> —33rr5 <br /> F _ <br /> 6(.16'1 <br /> Received by - Date Receipt No. - Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:, _-ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,PO.Sox 2009 STOCKTON,CA 95201 . <br />