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a _ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> R FOR OFFIC ft: APPLICATION <br /> ,. (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br />,, (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application i's hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or instaill the work herein described.This application is <br /> made in compliance with Spa oaouin Coupity 0 di rices Nc� 1662 rid the rules and regulations-of the San Joaquin Local Health District <br /> Exact Site Addres C� � r City/Town <br /> Owner's'Na` 0, 6 56 Phone � I <br /> Address ! - , O City <br /> .Contractor's Name License# .52f Z_S1 Business Phone 32— 3Z,_ <br /> Contractors Address G Emergency Phone <br /> Is Certificate of Workman's Compensation I ur nce 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❑ j <br /> REPLACEMENT❑ J (JG <br /> DISTANCE TO NEAREST: Septic Tank Serer Lines pit Prig <br /> Sewage Disposal Field—At0 1 Cesspool/Seepage Pit Other <br /> Property Line 0P_' Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL l �� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> %DOMESTIC/PRIVATE I <br /> e ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 It S <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal ! <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout t✓L I <br /> ❑ DISPOSAL~ ❑ OTHER Other Information y� <br /> 11 GEOPHYSICAL Surface Seal Installed By: 6 Lc' Y1 14--- .. <br /> PUMP INSTALLATION: Contractor <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 /> 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 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call ou n prior to grouting and'a final inspecti <br /> Signed X Title: _ I" ,V Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR ARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted <br /> By Date <br /> Additional Comments: j <br /> II Grout spection �f �+ P e I Final i pection / <br /> Inspection By v' Date 7b 'V Inspection By Date 6/4.�� <br /> Fee Is Due: F-1ANNUALLY [I PEP UNIT 11 PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ` <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> �f t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Y <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.,P.O.Box 2009 STOCKTON,CA 95201 <br />