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+� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. t <br /> FOR OFFICE USE: APPLICATION r <br /> (For Non-Transferable, Revocable,Suspendable) t <br /> PUMP&WELL i <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 1 <br /> (COMPLETE IN.TRIPLICATE) WATER QUALITY 25e—OZ-0 n <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein describedl.This application is <br /> made in compliance with Sa J a In Count O®rdinance No. 48rz2 and the rules and regulations of the San Jo�uln Local Health District. <br /> Exact Site Address g` { 4 �C City/Town / �` L y' -00, <br /> Owner's Name 1 Phone i <br /> Address City <br /> Contractor's Name ense# _k99'9 Business Phone <br /> Contractor's Address Qr - Emergency P one �7te <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With 5JLH0? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION//❑ DESTRUCTION El l <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOI`�,W PUMP REPAIR D. I <br /> REPLACEMENT❑ b <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines-_ ' - f Pit Privy <br /> - ti- Sewage.Di s posal.Fi el d 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 f Type of Grout <br /> © DISPOSAL ❑ OTHER Other Information p <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 4111p <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 /> k <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." y <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 Ins_pection_prior to grouting and a final inspection. ' <br /> Signed X � � 40E=: Title: , M 06 ,, Date: <br /> (Draw Plot Plan on Reverse Side) J ; <br /> 7ORDARTME T USE ONLY � <br /> PHASE 1 p <br /> Application Accepted By a Date <br /> Additional Comments: <br /> Phase II Grout Inspection ha 'nal Inspection ZS <br /> Inspection By Date ' Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Receive By January'31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> ' PflORAT10N ,. € <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> l <br /> OTHER ti <br /> fC4 h1_1 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITisERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201 <br />