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AppucauonsWill Be ProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION - <br /> (For Non-Transferable, Revocable, Suspendable) �� <br /> PUMP&WELL � <br /> — ENVIRONMENTAL HEALTH PERMIT t <br /> (COMPLETE IN TRIPLICATE) V !� S Y `��� WATER QUALITY <br /> Application is hereby made tot nJoaquin Local Heal{hlLilstrictfora permit toconstruct and/or install thework herein described.This application is <br /> made in compliance with Sar o lin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> \/AN- City/Town � rtc , >_ <br /> Owner's Name Phone <br /> Address d Gity T�� <br /> Contractor's Name _. p�_ �(1� License# 190'7 Business Phone <br /> Contractor's Address e- Emergency P one 4C. A <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION 4 <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION V PUMP REPAIR 41, <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 /> 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 Cl ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ Other Information q7 <br /> ❑ GEOPHYSICAL Surf e Seal Installed By: �- <br /> PUMP INSTALLATION: Contractor (I.a <br /> Type of Pump H.P. T' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call f Grout Inspection" <br /> rior o grouti and a final inspecti <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> OR EPART ENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: ::� _A40 <br /> Phase 11 Grout Inspection Ph a nal Inspection 9 <br /> Inspection By Date Inspection By Date r /�` <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received i 1 <br /> BILLING REMITTANCE $ R I <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHE <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 1 <br /> PENALTY tG�o% ��J 6t/n�!`G "� G -[.y+..r"e- <br /> OTHER <br /> e OTHER �UC Y-CG'✓a'sra•-f <br /> OTHER LvtFr1~+ �wsv O { fvc� <br /> 401. <br /> Received by Date Receipt No. permit No. Issuance Date Mailed Delivered <br /> ;� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 01/x..51601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 , <br />