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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-'HEALTH PERMIT -.7 <br /> (COMPLETE IN TRIPLICATE) .WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District f or a permit to construct and/or'install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and they rules and regulations of the San Joaquin Local Health District.,, L <br /> Exact Site Address ? ��� JL F�a— )n City/Town_ ' <br /> Owner's Name /'K �G�9 C v^ y« " Y-'° Phone' A 3 <br /> Address .3! I� a. ;��i ., - rp City <br /> Contractor's Name '` car � License#33W,_2/ Business Pho ems`-'L <br /> Contractor's Address PO Z6 .A -Tt. 6• Emergency Phone of <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L�� No <br /> TYPE OF WORK (CHECK): 'NEW WELL❑ ' DEEPEN ❑— RECONDITION❑ - DESTRUCTION,❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATION I� PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy s <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 0r,-, �INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 <br /> I�rpUMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMFSTIC/PUBLIC ❑ DRIVEN Gauge of Casing F <br /> f <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout V Sy <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL n SurfaceSeal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump-- H.P. <br /> � 1 <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 /> 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 to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"l 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 WALcaLl fora Grout Inspection prior to grouting and a final inspection. <br /> Signed Title: i:�..�� Date: a <br /> (Draw Plat Plan on R verse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> I Application Accepted By A a Date <br /> 4 Additional Comments: _ <br /> t Phase II Grout Inspection P a Ill"al al Inspection <br /> -Inspection By Date Inspection By Date -7-1,e-4' � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT D PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I REMIT ' <br /> BILLING. _REMITTANCE -$- <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> i <br /> FEE' <br /> LESS . y <br /> PRORATION <br /> PLUS <br /> PENALTY' <br /> t OTHER <br /> OTHER <br /> E <br /> -c Received-by- - `- Date Receipt Nor - Permit No. •I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />