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I FOR ICE USE: ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> O�FAPPLICATION <br /> I. <br /> Cb kvp/0.0 4 (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT / PUMP&WELL <br /> I (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> t made in compliancewit�oaq in County rdiin_ }ce No. 862 and the rules and regulations of the San Joaq in Local ealth District. <br /> Exact Site Addressa 11 V 2 City/Town <br /> 'e.42 4M6ffA- <br /> Owner's Name -A/41,11 r Phone <br /> Address C qo City tJ1 f <br /> Contractor's Name Ed .. License# 19�a 2461 Business Phone___ <br /> Contractor's Address wGL Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 11 <br /> REPLACEMENT❑ J <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 ` <br /> TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> f I, ❑ 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 Install 8y: <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 <br /> ,. Approximate Depth <br /> Describe Material and Procedure <br /> I <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 rulesland 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 persori 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 wi call for a Grout Inspec ' pri to outi g and a inal inspection. ('' <br /> \ , l r� <br /> Signed X ado itle: 6I"Ql' _ Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ++ f <br /> Application Accepted By - <br /> Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection s !1 F I Inspection G <br /> Inspection By Date Inspection By i�'� Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ <br /> January 1 R Received� 31 � my i &Received By July 31 <br /> '~ BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED , <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS , <br /> PENALTY i <br /> OTHER <br /> i <br /> OTHER <br /> p <br /> `Received by, Date _ rte Receipt No... Permit No. ssuance ate Mailed Delivered <br /> `"'APPLICANT=RETURN'AL�COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 M1E,:HAZELTON AVE.',P.O.Boa 1pp9 STOCKTON,CA 95201 j <br />