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ApplicationsWill BeProcessedWhenSubmittedProperly Completed. BeSureToSignTheApplication. <br /> -FOR GrFICE USE: APPLICATION �p j <br /> (For Non-Transferable, Revocable,Suspendable) '�r <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with! -7-7 3 <br /> San Joaquin County Ordin n e No 862 and the rules and egulations of the San Joaquin Local Health District. <br /> Exact Site Addressti� 4 �1� 6y �d/ City/Town <br /> Owner's Name r' _ Phone�` G9 <br /> i <br /> AddressCity ► <br /> Contractor's Name License # Business Phone <br /> 1 <br /> Contractor's AddressQ .T Emergency Phone <br /> Is Certificate of Work man's,Compe'nsation Insurance on File With LHD? Yes L---' No <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ 'DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION Kra PUMP REPAIR❑ <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 /> ❑ IN.P�USTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <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 . �' �c�f - 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 /> lT' <br /> l 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 w' I yPr a Grout 12ection prior to grouting and a final inspection. J <br /> Title: '+r-c_4 Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection se III Firayajl inspection <br /> Inspection By Date Inspection By 11 Date <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 $ REMIT <br /> BASE EXPLANATION DATE DATE MITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS y <br /> PENALTY <br /> OTHER <br /> OTHER Id <br /> F <br /> 5 9 30 Z9m <br /> Received by Date Receipt No. Permit No. 'llissuancepatef Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ <br /> 1 , <br />