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y,pplicatfons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. v <br /> ,9E: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> _ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is } <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address CZ 4 0 h- ' / (A/i�7 City/Town G` d <br /> Owner's Name Phone 3 r <br /> Address City rte' -e <br /> Contractor's Name Licens4ky_Mz Business Phone jg1ler 2 <br /> Contractor's Address Emergency Phone 4 <br /> r v a <br /> Is Certificate of Workman's Compensation I,nnsurape on File With SJLHD? Yes C� No <br /> TYPE OF WORK (CHECK): NEWWELL ' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ . OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ } <br /> DISTANCE TO NEAREST: Septic Tank f SewerYLines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well ! (JAPublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation lz5 <br /> k <br /> 11DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing `Q <br /> 9?I'RRIGATION ❑ GR L PACK' Depth of Grout Seal �} <br /> ❑ CATHODIC PROTECTION OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information %z <br /> d <br /> ❑ GEOPHYSICAL Surface Seal Installed By: -� <br /> PUMP INSTALLATION: Contractor <br /> i H.P. <br /> i; <br /> --,--I Type of Pump � <br /> PUMP REPLACEMENT:- ❑ State Work Done <br /> PUMP REPAIR:- k� ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 4-- Ay-,e-IA/ Approximate Depth 0 Z <br /> Describe Material ajnd Proce' dure <br /> 22r- <br /> 1 hereby certify that I have prepared this application and that the work will be done in ac.ordance 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 forwhich 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:"l 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 <br /> c II for a Grout Inspection prior to gr uti g and a final inspection. <br /> Signed X � 2. r Title: ',� ��'`s'��� _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase Il Grout Inspection III I Inspection <br /> Inspection By Date InspectioJ..,,,.d <br /> Date <br /> Fee IS Due: ❑ ANNUALLY '© PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 By January 31. ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE $ RE <br /> M}T <br /> BASE ^� EXPLANATION DATE DATE REMITTED r AMOUNT pUE CHECKEp <br /> AMOUNT � <br /> FEE <br /> LESS <br /> PRORATION ;rt <br /> PLUS + 1 <br /> PENALTY <br /> OTHER / (I (J I✓l6�il'<- t �Ll.f/-sir -�C �rUG I-, <br /> 1 <br /> i <br /> OTHER 4 S <br /> Received by pate Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.eox 2009 STOCKTON,CA 95201 <br />