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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) PUMP&WELL / <br /> ^ ENVIRONMENTAL HEALTH PERMIT (/l/ <br /> (COMPLE?TE IN TRIPLICATE) C2.5 WATER QUALITY v(3-250 r Z_3 <br /> Amlication is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance ith n oaqui County Ordinance No.i8 2 and the rule an re lations of the San Jvaqui Local Health District. <br /> Exact Site Address r r [ a City/Town <br /> Owner's Name <br /> / Phone <br /> Address — y 19 nr _Jt r City .. [, 2116 <br /> Contractor's Name License#:� Z.7_f_�� Business Phone R 7 /O t <br /> Contractor's Address Emergency Phone �. <br /> Is Certificate of Workman's Compensation In ura_nce on File With SJLHD? 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❑ <br /> DISTANCE TO NEAREST: Septic Tank ,SG1 �-} Sewer Lines Pit Privy <br /> Sewage DisposalFeld Cesspool/Seepage Pit .— Other <br /> Property Line 1Q 1 Private Domestic Well !� `{' Public Domestic Well -� <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL J CABLE TOOLr' <br /> Dia. of Well Excavation Zo <br /> ❑ DOMESTIC/PRIVATE © DRILLED Dia. of Well Casing f' <br /> ❑ DOMESTIC/PUBLIC Cl DRIVENI '1 <br /> Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ <br /> 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 /> 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." t <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 will call for rou Ins ti �Prior togrouting and a final inspection. <br /> Signed X Title: +t Date: f r I <br /> (Draw Plot Plan on Reverse e)w <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date ,��1-�� <br /> Additional Comments: <br /> Phase 11 Grout In pecti t Phase III Final Inspection a <br /> Inspection By ybw Inspection By Ab <br /> Fee J�j[r�{��D�ate `(���`j��Rt <br /> t=ee IS Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 3Y hF,}u}y 1 &�ReceiBILLING REMITTANCE $ R • <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> EEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 �� - <br /> Received by Date Receipt No. Permit No. Issuarte Date Mailed -Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />