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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> / JtJ4,2 (For Non-Transferable, Revocable, Suspendable) PUMP&W�LL <br /> o <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 Count Ordinance No.1862 and the rules and regulations of the San Joa ui ocal,`4aLh District. <br /> Exact Site Address •�l 9 4�it6✓ Ll City/Town <br /> w � t <br /> Owner's Name L)w'rL. ti j GL.. <r'Q " a Phone_ <br /> Address Tf� � S 1941 s 4Jt � —__ __ City &244 C <br /> Contractor's Name License#US-77 Business Phone J&2- -740,6 <br /> Contractor's Address Emergency Phone ^�\ <br /> Is Certificate of Workman's Compensation Insurance on F'a With SJLHD? Yes No Axl <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 <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 /> 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 Inst led By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: M State Work Done ul_ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dept -`9 <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 will call for a Grout dnspe do or to jr uting aroA final inspection. <br /> Signed .. INe: N1 Date: /� /� O �� <br /> (Draw Plo anJon Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 pQ^1 <br /> Application Accepted By D Date 4n1a O <br /> Additional <br /> Comments:- <br /> hase 11 Grout Inspection Phas�I-�I-�I FF'�' al Inspection <br /> Inspection By Date Inspection By G���'� Date ��r . <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> 5fS o Z3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY { <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance 0ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />