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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ' v (For Non-Transferable, Revocable, Suspendable) I <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with quin County Ordinance No. t 52 an t rules and regulations of the San oaqu'n oval Health District. i. <br /> Exact Site Address_._ I W�� L WQ.�` _ — City/Town j <br /> r <br /> Owner's Name RALCPhone T <br /> Address 411 City— Jr® a 7 rt► :: Cis , <br /> Contractor's Name License# Business Phone <br /> Contractor's Address - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes-� No `L d <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ .E <br /> DISTANCE TO NEAREST: Septic Tank 106 Sewer Lines n Pit Privy — <br /> Sewage Dispo l Field ( Cesspool/Seepage Pit Other ? <br /> Private Domestic Well Public Domestic Well 4 <br /> Property Line ' <br /> INTENDED USE TYPE OF WELL rj <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of'Well Excavation r <br /> fn <br /> pOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN , Gauge of Casing "` <br /> Of <br /> ❑ IRRIGATION RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTIONOTARY Type of Grout "� <br /> El DISPOSAL '❑1OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �y <br /> PUMP INSTALLATION: Contractor ' <br /> .. s <br /> Type of Pump H.P. <br /> PUMP REPLACEMEN �"� StateWork Done <br /> T: <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 performanceof thework 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." y. <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this i; f <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will_paWlor a Grout In a ion prior to grouting and a final inspection. <br /> Signed X Title: <br /> __dy .J Date: <br /> (Dr Plot Plan on Reverse Side) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Datew <br /> Additional Comments: <br /> Pha a 11 Grout Inspection Phase III Final Inspection <br /> r, i <br /> inspection By Date Inspection By Date ��—t� <br /> S <br /> Fee Is Due: ❑ 'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILONG REMITTANCE $ <br /> RASE EXPLANATION DATE DATE REMfTTED AMOUNT DUE CHECKED - r <br /> AMOUNTy, <br /> .� <br /> FEE � �� l� �-.� ! - <br /> LESS <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER T <br /> IReceived by Date Receipt No. Permit No t l9suancd Date Mailed Deliveretl. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 i <br />