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r pplications Will Be ProcessedWhenSubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> t -- (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 thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Lo/cal Health District. <br /> Exact Site Address �� CA- «r� City/Town <br /> Owner's Name r-, , /� Phone <br /> `t City Bev, r,f -1-e— <br /> Address (o"7 <br /> Contractor's Name �' s; �a✓Imo'�+ �� �' +' �J License#� $ ! .3 Business Phone <br /> Contractor's Address ycldd Ah 5-d ii-114ES /9<g rylea Emergency Phone Q ry —�— <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ;. <br /> TYPE OF WORK (CHECK): NEW WEL)K 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 Fiiellld, Cesspool/Seepage Pit Other <br /> Property LinePrivate Domestic Well Public Domestic Well <br /> 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 /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL _/j // Surface Seal Installed-ply �� /' <br /> PUMP INSTALLATION: Contractor J�/�iY 4. e G � , <br /> Type of Pump sCe.�h.�/t `��� 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 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 call fora Grout pe/cttion prior to grouting and a final inspection. <br /> �F-tc <br /> Title: <br /> Signed Date: <br /> Signed X r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I } n (y'r{-� / <br /> Application Accepted By I'i �� Date <br /> Additional Comments: <br /> Phase 11 Grout InspectionQ�' ha e III Final Inspection <br /> Inspection B <br /> D,yte D r G L ---- Inspection B Date <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received <br /> REMIT <br /> uly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE _ ; <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt NO. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES,TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />