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Applications will tie Processed when 5ubmilted Properly Completed. Be Sure To Sign The Application. <br /> r FOR OFFICE USE: ` �{ APPLICATION <br /> �0 � G (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <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 San Joaquin County Ordinance No. 1862 a d the rules and regula®tions of the San Joaquin Lo I ealth District. <br /> Exact Site Address 1/400 .2 � 5► Mme( City/Town �] V zi <br /> Itt. t <br /> Owners Name "l get :[>a 14t e a 1. Phone_ <br /> Address •/ a A L C <br /> ` �7 ty <br /> Contractor's Name EV= License#_JJW!7 � Bsiness Phone_ <br /> Contractor's Address <br /> 67 <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With LHD? Yes X No \ 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> t. WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRaT <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> the, <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 /> sea ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing <br /> Pqy IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> w ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r{ <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �y Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _C <br /> PUMP <br /> Type of Pump T.. #1&&4,, � •• H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 59 State Work Done C aoa✓ K <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dep h <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 subcontracting signature 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 w'I call for a Grout Inspec p tor,16-5-Fluting and a final inspection. <br /> Signed Xi ri.� Title: ?/rPX Date: <br /> (Draw Plo Plan on Reverse Side) <br /> R DEPARTMENT USE ONLY 'S <br /> PHASEI [ <br /> Application Accepted By /���t.�—�zZ�� DatQ- - - <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t&Received By January 31 ❑ July t&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> it <br /> FEE 9 <br /> LESS <br /> PRORATION <br /> PLUS `!(� <br /> PENALTY IF IF <br /> OTHER J9 <br /> OTHER <br /> \ - tntcis%7 81 A9 7 W <br /> 4 > �teceived by Date Receipt No. Permit No Anuarnal Date Mailed Delivered �- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL;fEALTH FERMRKERVICES 1501 E.HAZELTON AVE.,P.O.au 2001 STOCKTON,CA 952U1 <br />