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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFACE.USE; APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabfe) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) X23 -, �AL[TY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permito construct and/or install thework herein described.This application is <br /> made in compliance wi+'' ,a oaquin Count finance No. 1882 and the rules and regulations of the San aq Local Health District. <br /> Exact Site Address C51, City/Town N C4.r <br /> Owner's Name Phone __ <br /> Address <br /> Contractor's Name _57. ,� License# (��SJ Business Phone <br /> Contractor's Address 1 Emergency Phone <br /> Is Certificate of Workman's ompensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 2�r_ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 3�—_7FUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tan*6!��IJ/ef — Sewer Lines Pit Privy <br /> Sewage Disposal Fieldo&� �/Il Cesspool/Seepage Pit .fi a�*-� _ Other <br /> Property Line Private Domestic Well 1_5pe"6 Public Domestic Well '� t <br /> INTENDED USE TYPE OF WELL ®I21Y <br /> ❑ INDUSTRIAL ❑ <br /> CABLE TOOL Dia. of Well Excavation <br /> O ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Z a <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION 2F'VRTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information f" <br /> ❑ GEOPHYSICAL Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ci , H p <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performanceof 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." ,4 <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 em I y rsons subject to workman's compensation laws of California." <br /> will call for a Gro etl prl r to <br /> routing and a final inspection. <br /> Signed X t Title: - Iy rw\ ,, Date: , <br /> (Draw Plot Plan on Reverse Side) f <br /> FOR DEPART ENT USE ONLY <br /> TPHASEI <br /> Application Accepted By Date "/7 <br /> U 1 <br /> Additional Comments: <br /> Ph se II Grout Inspection P ase III Final Inspection <br /> Inspection By Date Inspection By� X71 Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT U7PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE (0 L_ <br /> LESS 6 4 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t <br /> Received by Date Receipt No. ermit o. Issuance Date Mailed De ivered <br /> APPLICANT—RETUR ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTDN,CA 95201 <br />