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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FC?R OFFICE USE: APPLICATION C/ r <br /> (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ,2c� ZO _ J�G6yLew)¢� TER Ql1ALITY E7_ 3-7-D--6,v <br /> Application is hereby madetotheSan Joaquin Local Health Distri tf rapermittoconstructand/or installthework"herein described.This application is <br /> made in compliance with San Joalgpin County Ordinance No.1�8f62 and the rules and regulations of the San Joaquin Local Nealph District. <br /> Exact Site Address /!/<. FA2I. J/7 r<! t City/Town �� <br />[-- ,Owner's Name Jam" " !/he fr: I- Phone � <br /> Address O far.�� .isV_ _Ity ,y� .� r " <br /> Contractor's Name /G License#C6/- 'Business Phone v-1 <br /> e i <br /> Contractor's Address .2-23 RAa --. Emergency Phone [ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No -� # <br /> TYPE OF WORK (CHECK): NEW WELL . ` DEEPEN ❑ RECONDITION❑ DESTRUCTION❑" <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION K PUMP REPAIR❑ I <br /> REPLACEMENT❑ <br /> i <br /> DISTANCE TO NEAREST: Septic Tank <br /> �Q Sewer Lines 40� Pit Privy <br /> C Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic well <br /> INTENDED USE TYPE OF WELL <br /> 13 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation - 41 <br /> DOMESTIC/PRIVATE Y' DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information , <br /> ❑ GEOPHYSICAL / Surface S I fns Iled By: _ <br /> PUMP INSTALLATION: Contractor I� ;i '�� ! � <br /> s Type of Pump H.P. �~ <br /> u PUMP REPLACEMENT: ❑ state Work Done .� <br /> PUMP REPAIR: ❑ State Work Done eP , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure N 5 <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 /> r Home owner or licensed agent's signature certifies the following:"I certify that*in the performance of the work for which this permit <br /> j is issued, I shall not employ any person in such manner as to become subject to,workman's compensation laws of California." <br /> It 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 compensatioh'l'aws of'California." <br /> I will call for a.Grout inspection prior to grouting and a final inspection. <br /> Signed X Title: ,�� � � Date: g �� <br /> (Draw Plot Plan on Reverse Side) <br /> . i, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE t <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase fl Grout Inspection /Phase III Final Inspection <br /> Inspection By Date Inspection ByDate <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH; [3 January 1 &Received By January 31 ❑ July 1 &Received By July 37 1 <br /> ` I REMIT 1 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITT <br /> AMOUNT ; <br /> FEE ! <br /> LESS <br /> PRORATION ' <br /> PLUS. <br /> ' PENALTY <br /> OTHER <br /> OTHER W <br /> ti S&73 C �� <br /> Received by D to Receipt No. Permit No. Issuance Date .Mailed. Delivered <br /> 5201r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA S! <br /> i <br />