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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <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 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 and the rules and regulations of the SarlJoaquii Local Health District. <br /> Exact Site Address ' L City/Town 71- <br /> Exact <br /> Owner's Name r f% _ Phone <br /> City <br /> Address - ? F `� "�`r�/ Td Nib' —U <br /> Contractors Name . rfJ/ r r" License#yJ!!7f Business Phone G_� 6: <br /> Contractor's Address"Jf. �.< .i K Emergency Phone d=f��r" <br /> Is Certificate of Workman's Compensation Insurailce on File With SJLHD4 YesL•• _ No <br /> TYPE OF WORK (CHECK): NEW WELL 13 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 ��G' �'� <br /> Sewage Disposal Field Cesspool/Seepage Pit AJ,- -__ Other <br /> Property Line__ Private Domestic Well _ Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Die. of Well Excavation <br /> ❑ DOMESTIC/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: t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done` J ' .� Sy,�F < vt1,LL/ ✓ .u/ r a /' <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> �•14 f.,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. h <br /> Home owner 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 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 will call for a ,rout I ction prior to grouting and a final Im; n. <br /> Signed X _s•- g°"�fi�{ Tltle: �+ - `" Date: r� <br /> � - (Draw Plot Plan on Reverse Side) ~-- <br /> FOR DEP TMENT USE ONLY <br /> PHASE <br /> Application Accepted By�—y � >ac ---�^ Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Inspection By� Date Inspection By _ Date <br /> Fee Is Due: 13 ANNUALLY J❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ,J{3a AMOUNT <br /> FEE Y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER D "� <br /> `?r1-110 Ul1//36 aagy rte- _7-.-2- 3.s/ zi <br /> Received by crate Receipt No. Permit No. Issuance Date Mailed Dellvered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Dox 2009 STOCKTON,CA 95201 <br />