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FOR OFFICE USE: APPLICATION <br /> 'For Non-Transferable, Revocable,Suspendabif <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 a Joaquin ounty Ordinance No. 1862 t e rules and regulations of the San uin Local Health District. <br /> Exact Site Address City/Town �''rc y- <br /> Owner's Nam T>L Phone <br /> Address City <br /> Contractor's Name r icense#+jG Business Phone -- __. <br /> Contractor's Address - Emergency Phone a7Y <br /> Is Certificate of Workman's Compensaion Insurance on File With SJLHD? Yes No I <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy (y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other V <br /> Property Line Private Domestic Well Public Domestic Well <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 <br /> ,Z'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout O <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <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 /> 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 wl all for a G out In on prior to grouting and a final inspection.�---,¢� <br /> Signed X U r>v<%+.. Title: IQ?[<4- ys(iJ Date: <br /> (Draw Plot Plan on Reverse Side) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q// <br /> Application Accepted By— Date jWYZq <br /> Additional Comments: <br /> Phase 11 Grout Inspection has 111 Final Inspection <br /> Inspection By Date Inspection By to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i&Received By January 3 J9 ❑ July 1 8 RCCewtxt By July 31 <br /> REMIT <br /> BILLING REMITTANCE E <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O <br /> 79-\�.-.% I I74/I <br /> ReceiveE by Date Receipt Noby Date Receipt No. Pernut N6, ssuance Date Mailed DeliveredDate M.BW Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />