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f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appllca ion. <br /> l A <br /> I FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) ` Lp�. <br /> ENVIRONMENTAL HEALTH PERMIT - PUMP&WELL <br /> r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This app ication is <br /> made in compliance with San ijoaquin County Ordinance o. 1862 and the rul s and regulations of the San.,4oaquin Local Health District. <br /> { Exact Site Address d+�r`+ ��< City/Town <br /> Owner's Name 't Phone 3 "s <br /> z� iN <br /> Address 7 C.J� City <br /> Contractor's Name ✓�� License <br /> # '�f Business Phone " j <br /> Contractor's Address 64 S7. Emergency Phone <br /> Is Certificate of Workman's Comppensation Insurance on File Wit SJLHD? Yes No <br /> ' TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> :I I <br /> ' OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC I ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 0 <br /> ❑ GEOPHYSICAL ---� ��. ._ Surface Seal Installed By: <br /> t PUMP INSTALLATION: Contractor 4—CJ��, 6, t: �r <br /> Type of Pump. j4 H.P. � 5 f <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: © State Work Done <br /> DESTRUCTION OF WELL: i Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I.Pave 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 fr a Grout Inspection prior to grouting and a final inspection. <br /> Signet/ X Title-. ✓ Date: <br /> 1� (Draw Plot Plan on Reverse Side) <br /> J FOR DEPARTMENT USE ONLY <br /> PHASEI / <br /> Application Accepted By .2�` �1 <br /> _ Date "Z <br /> Additional Comments: �M <br /> Phase 11 Grout Inspection a III Fin I• nspection <br /> Inspection By DateInspecti By ate G <br /> 111� G <br /> Fee IS Due: 11 ANNUALLY J ElPER UNIT ❑ PER SITE ❑ EACH ❑ January 1'&Received By January 1 0 ❑ July 1 &Received By July 31 <br /> FFBILLING REMITTANCE $ REMIT <br /> BASEL! EXPLANATION ATE REMITTED AMOUNT DUE CHECKED <br /> DATE D <br /> I� AMOUNT <br /> FEE <br /> r LESS <br /> PRORATION JL <br /> F PLUS `I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> illy n C414 312-1 ; ��C _21_-,,?Y/ _ <br /> * Received by Date 4 Receipt No. Permit No, _ Issuance Date Mailed Delivered <br /> APPLICANT—RETURN_ALL COPIES TO:: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AYE.;P.O..Box 2009 STOCKTON,CA 95201 <br /> p - — - <br />