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Applications Will Be Processed WhenSubmitted ProperlyCompletes BesureToSlgn ineAppncanon. <br /> ' <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work 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 Local Health District. <br /> Exact Site Address Q t City/Town -%7 <br /> Owner's Name �/ 1✓� Phone 56q— / 3,2 <br /> Address City 49p/ D <br /> Contractor's Name 611 i3`- �� d#+�ZC� 1� GL��CL License# usiness Phone 7'y'7`e— 3 ;_777 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes il_� No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITIONIK DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR© <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /00 Sewer Lines fes} Pit Privy <br /> Sewage Disposal Field — Cesspool/Seepage Pit ' — Other <br /> Property Line / 1`�� Private Domestic Well Public Domestic Well °�7— <br /> INTENDED USE TYPE OF WELL 'r/ <br /> ❑ INDUSTRIAL P9-CABLE TOOL Dia. of Well Excavation _ <br /> 10 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 5' Q4_0 > r� <br /> ❑ DOMESTIC/PUBLIC ❑.DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout /uz <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: % C~] <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work 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 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- all for a Groiyt Inspection prior,to grouting and a final inspection. <br /> I{/ �� a <br /> -�--� (=�'�4-L L�'� f� Date- <br /> Signed X � �"���'�`� Title: � <br /> (Draw Plot Plan on Reverse Side) <br /> F DEPA MENT SE ONLY <br /> PHASE I _. <br /> Application Accepted ByQ / Date <br /> Additional Comments:-----/ <br /> Phase II Grout Inspection Paha I final in clion �Q <br /> Inspection By Date �� Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANA ION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATSON< <br /> PLUS ; <br /> PENALTY <br /> OTHER <br /> OTHER <br /> d 59� <br /> Received by Date Receipt No Permit No Issuarlbe Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br />