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x Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR oFpICE USE: APPLICATION "-r <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT {/ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> --Of '' <br /> Application ishereby m of nJ ocal Health Districtfora permit to construct and/or install the work herein described.This application is w <br /> made in compliance o in nTy Ordinance No. 1862 an the rules and regulations of then San Joaquin cal Health District. � <br /> Exact Site Address! 7 — <br /> Owner's Name AMAf Phone �"�SF 9 _ <br /> Address � 6+ 3 City f/ W _ a <br /> Contractor's Name License# c2M&3 Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL U�-' DEEPEN ❑ 41 RECONDITION❑ DESTRUCTION❑ I' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ j <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Z02.0 — Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well it <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 ��L116z.�� <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, i <br /> PUMP REPLACEMENT: ❑ State Work Done 4 <br /> PUMP REPAIR: ❑ State Work Done R <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> 1 <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. y <br /> 'i <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 J <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Wipe prior to grouting and a final inspection. �/ 6?z Signed X Title: ��+ Date: <br /> (Drawpf lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE If <br /> Application Accepted By Date <br /> Additional Comments: 4 <br /> se rout Inspection / j Phase III Final Inspection <br /> Inspection By .01 Date 7 r Inspection By d`✓.'a Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JuVy 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUECHECKED <br /> DATE DATE REMITTED . <br /> �q AMOUNT � <br /> FEE "Y43 <br /> LESS <br /> PRORATION <br /> F <br /> PLUS F <br /> PENALTY <br /> OTHER <br /> OTHER <br /> } <br /> i <br /> Received by Oat4 Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P:O.Box 2009 STOCKTON,CA 95201 <br />