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i Applications Will Be Processed When Submitled Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFS USE: APPLICATION <br /> (For Nan-Transferable,.Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)';?0Q3_y r/�G77�/�LD WATER QUALITY <br /> ! Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin ount Ordinance No. 1$62 and the rules and regulations of the San Joaquin Lpcal Health District. <br /> Exact Site Address 011 !d rCit /Town l <br /> Owner's Name ht1P co Q Phone _ <br /> Address City !� ?�2 e ?77,0L/� <br /> Contractor's Name AJY f License# 761 Business Phone `1K <br /> I Contractor's Address d dwV Emergency Phone <br /> Is Certificate of Workman's Compensation Insuratc,on File With SJLHD? Yes_Z-- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ VV <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION &— PUMP REPAIR❑ N <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank r_ I �. Sewer Linesr Pit Privy W <br /> Sewage Disposal Field t G It r Cesspool/Seepage Pit Other_ <br /> Property Line Private Domestic Well Public Domestic Well <br /> E INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ® <br /> ­DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> t ❑ 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 /> I PUMP INSTALLATION: Contractor V!✓ i v <br /> I <br /> Type of Pump L f H.P. <br /> PUMP REP',ACEMENT: 13State Work Done d <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 /> I 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 will tail for a Grout Inspection prior to grouting and a final inspection. <br /> i <br /> Signed X _. `�_ Tille. X — _ Date: 2 , C <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> i PHASEI <br /> Application Accepted By Date /A _A7 <br /> Additional Comments: <br /> Phase tl Grout Inspection a. 111 F' al Inspection <br /> Inspection By Date Inspection By D to <br /> - <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AM NT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4� 7 0a <br /> Received by. Date Receipt No Permit No. - /Issuant;4 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 />