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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> a <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaqui n Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquig County.Ordinance No. 1862 and the rules a d re lation ��je!! an Joaquin Local Health Distric . <br /> Exact Site Address `� CI yt�ov7li --_I:LP ,Q.CL - <br /> Owner's Name Phone ZXl <br /> Address city <br /> Contractor's Name License#�, Business Phone ���i�� C, <br /> Contractor's Address 1 Emergency Phone 5XS—_—ZW 7/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No >�! <br /> TYPE OF WORK (CHECK): NEW WELL qV' DEEPEN ❑ RECONDITION❑ DEST.RUCTION❑ V <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ —OTHER ❑ PUMP INSTALLATION D,o _sPUMP.REPAIR❑ <br /> REPLACEMENT❑ ll r7/ _ <br /> DISTANCE TO NEAREST: Septic Tank 6/ Sewer Lines T 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 /> • // /� F <br /> �DOMESTlC/PRIVATE 11 DRILLED Dia. of Well Casing (? P Y(../ T <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION WGRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION W/ROTARY Type of Grout <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: + <br /> PUMP INSTALLATION: Contractor <br /> t" Type-of Pump - - H.P. fi <br /> PUMP REPLACEMENT: ❑ !tate Work Done - <br /> PUMP REPAIR: ❑ State Work Done \ t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1� <br /> Describe Material and Procedure <br /> I <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 forwhich 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 signalure.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 all for a Grout Inspe t' n p�for to grouting and a linal-inspe <br /> Signed X 4-AJA, Dater <br /> f (D aw Plot Plan on Reverse Side) <br /> F R DEPARTMENT SE ONLY � <br /> PHASE I <br /> Application Accepted By ��JDate <br /> Additional Comments: <br /> se 11 Gr ut Inspection III Fi a! Inspection <br /> Inspection By Date �� 3 610. - _ Inspection By _ Date <br /> 7-- <br /> Fee <br /> -Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July, 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS ✓ <br /> PRORATION <br /> PLUS <br /> PENALTY { <br /> OTHER <br /> OTHER . <br /> 'i _ <br /> C - Z-3-FM X73 - Z/3/Era _ { <br /> Received by Date- . -Receipt No. M •Permit NoI suance Date' ' ^-Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />