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/ Applications.Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication <br /> FOR OFFICE USE: APPLICATION <br /> �- (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER-QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin CouOrdinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> I Exact Site Address nt� � 'Zos City/Town e M a <br /> Owner's Name Phone (ate? <br /> i Address rfa� City <br /> t Contractor's Name&aC,, A u i C 6Ae 13n;-1 J�v5 License#-?-f V Business Phone <br /> t Contractor's Address 02006 Emergency Phone /-)e, <br /> y. Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELI112r DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION>< PUMP REPAIR❑ qR <br /> REPLACEMENT❑ �? <br /> I DISTANCE TO NEAREST: Septic Tank - (�- _ Sewer Lines ASd Pit Privy A O <br /> Sewage Disposal Field o Cesspool/Seepage Pit _ 476/+/e Other d�� <br /> i Property Line Private Domestic Well (ooh Public Domestic Well <br /> i INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -� <br /> t ❑ CATHODIC PROTECTION ❑ ROTARY l� Type of Grout <br /> ❑ DISPOSAL ❑ OTHER 'Other Information <br /> ❑ GEOPHYSICAL ., Surface Seal Instalied By: <br /> PUMP INSTALLATION: Contractor 'M <br /> Type of.Pump A€-Y+fn,na�D- Sic b. H. A/I P. i <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 /> ,,,-isissued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Co'ntractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> -4:� permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ,,,I Till call for a Grout Inspection prior to grouting and a final inspection. <br /> C <br /> i Signed .� 0— <br /> Title: 0^ Date: <br /> .X` _S 1 ` - <br /> k t (Draw Plot Plan on Reverse Side) <br /> i� <br /> DEPARTMENT USE ONLY <br /> PHASEfI (/ d <br /> Application Accepted By o' Date <br /> Additional Comments: <br /> J�fPhos I Grout J41spection _ has Fi 1 Insp Ion <br /> Inspection By-- Date `� a` Inspection By e �� Q <br /> Fee is bue: ❑ ANNUALLY E3 UNIT EXPER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> } 'OF REMIT <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> h DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ` <br /> d PENALTY <br /> OTHER' <br /> OTHER <br /> Received by Date Receipt No. Perm it-No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />