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Applications Will Be Processed_ When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION (DON <br /> 4L (For Non-Transterable,'Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance w' aqui y Or�ljn an a ules and regulations of the San Joaquin t�l He th District. <br /> Exact Site Address N Y Qf,( 7 City/Town S <br /> x ` � <br /> Owner's Name' AJ d Phone 3 �� <br /> C Address W Cityit <br /> Con�ractor's Name ; L License#i3 Business Phone <br /> Contractor's Address Emergency Phone <br /> - Is Certificate of Workman's Compensation Insur ce on File SJLHD? Yes No <br /> + TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ . RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ U <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy U <br /> Sewage Disposal Field Cesspool/S�epage Pit Other <br /> Property Lin0Private Domestic Well P Public Domestic Weil <br /> INTENDED USE TYPE OF WELL <br /> X❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 2 �7U <br /> DOMESTIC/PRIVATE" ❑ DRILLED Dia. of Weil Casing <br /> ❑ DOMESTIC/PUBLIC T ❑ DRIVEN Gauge of Casing 2— <br /> IRRIGATION <br /> IRRIGATION ❑�GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION }'� ROTARY Type of Grout 9� V...) wr <br /> ❑ DISPOSAL ❑ OTHER _ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> F y: <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 p` <br /> 1 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:"1 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 /> iii Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I mploy persons subject to workman's compensation laws of California." <br /> r I II f a Got n rio grouting and a final in'spjec n./J ��/ , / '}_ T <br /> I Signed X Title: V GrC_ W 14 Date:ZV V <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date V I' <br /> Additional Comments: <br /> ase-11 t pe lion l Phase III Final Inspe !on <br /> Inspection B u` Inspection By ' to <br /> Fee Is Due:.❑"-ANNUALLY ❑ PER UNIT ❑ PER SITE _ ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> - REMITTANCE $ REMIT <br /> BASE EXPLANATION BILLING <br /> ' DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> �y <br /> r' �r- t o <br /> FEE `6 l 2 V a <br /> @1 LESS <br /> L PRORATION r <br /> i PLUS ' <br /> PENALTY <br /> *OTHER <br /> OTHER <br /> r <br /> ti <br /> Received by - pate Receipt No. Permit No -issuanch Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: *ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.-P.O'.Box 2004 STOCKTON,CA 95201 <br /> { ... <br />