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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> R dFFICE USE: APPLICATION <br /> For Non-Transferable Revocable, Sus endable <br /> (,r�'►+'it,�iO �'. { � P ) PUMP&WELL <br /> 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 thework,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and/the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address AM r-k/t lnr l n�/�e�.J�wow <br /> / City/Town <br /> Owner's Name Z.) Phone IV&2" to <br /> Address City_ ► <br /> Contractor's Name Cir License#A ^�� Business Phones7w <br /> ` Contractor's Address 1C .► r,/ iJ gt. Emergency Phone ! <br /> Is Certificate of Workman's Compensation Insurance on File SJLHD? Yes No o� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[]- <br /> WELL <br /> ESTRUCTION❑WELL CHLORINATION-E] WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> " Sewage Disposal Field -.—Cesspool/Seepage Pit Other F <br />! Property Line Private Domestic'Well Public Domestic.Well <br /> INTENDED USE TYPE OF WELL ++» <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation OQ <br /> ® DOMESTIC/PRIVATE ❑ DRILLED" -, ,.r ,. Apia. of Well Casing W <br /> ❑ DOMESTIC/PUBLIC �..- ❑ DRIVEN Gauge of Casing h <br /> IRRIGATION 11 GRAVEL PACK Depth of Grout Seal �+ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY" Type of Grout <br /> DISPOSAL <br /> ❑ C1 '�� YP ` <br /> OTHER Other Information ^� <br /> © GEOPHYSICAL - -Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu _�]_��6 � <br /> mp .A.-� A. H.P. 0 <br /> PUMP REPLACEMENT: ❑ State Work Done a.. . <br /> PUMP lam: JR 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 /> Home owner or licensed agent's signature certifies the following:1 certify that in the performance of the work for�hich this permit <br /> f 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 w I tali for a Grout In pe do pridr to outing and a final inspection. t ' <br /> e <br /> Signed Title: _ Date: <br /> (Draw PI Plan on Reverse Side) <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> 'Additional Comments: <br /> Phase II Grout Inspection Aase Ill Fal Inspection <br /> Inspection By Date _ Inspection By l Date z ' <br /> Fee Is Due: ❑ ANNUALLY ' ❑ PER UNIT ❑ PER SITE -❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July"31 <br /> REMIT IV , <br /> BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ' <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ti <br /> LESS 1 <br /> PRORATION - <br /> PLUS <br /> PENALTY f ^• - <br /> r <br /> OTHER <br /> OTHER O r <br /> Received by - Date - - Receipt No., - Permit No. <br /> .—Assuan6e Date Mailed Delivered - <br /> " APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />� f <br />