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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION a <br /> k (For Non-Transferable, Revocable, Suspendable) <br /> } <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WALL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY W <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto constructand/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Or finance No. 1862 and the rules and regulations of the San Joaquin ocal Health District. V <br /> Exact Site Address City/Town [- <br /> Owner's NamecAm le ell Phone Z <br /> Address Cltyae <br /> Contractor's Name t/C & v License# Business Phone G <br /> Contractor's Addres A42 Emergency Phone P' R <br /> Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes 4- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT--❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> r <br /> DISTANCE TO NEAREST: Septic Tank / Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line rivate Domestic Well Public Domestic Well <br /> INTENDED USE TYFC: OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> # ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑�'DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 9 <br /> I IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: C <br /> PUMP INSTALLATION: Contractor Iz Pr v J <br /> Type of Pump `[! P- `� -4 <br /> 4 <br /> PUMP REPLACEMENT: Q State Work Doneee►nu-,/ ;I T i4� 7 7 S <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> v <br /> f 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 certity 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 forwhich this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t w'I call for a Grout Inspection prior fv grou 'ng and a <br /> final inspec ' <br /> Signed X Title' lef., Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT SE ONLY <br /> PHASE I G �9 <br /> i <br /> Application Accepted By - Date <br /> Additional Comments: <br /> f Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date . <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH t` ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - - - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE- w DATE REMITTED m AMOUNT <br /> P <br /> FEE 01 <br /> LESS U <br /> PRORATION <br /> PLUS �- <br /> PENALTY r <br /> OTHER <br /> I, <br /> OTHER <br /> Received byDate # Receipt No. - Permit No. Iss ante bate Mailed - Delivered <br /> I-- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH,PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2D09 STOCKTON,CA 95201, <br />