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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign TheApplication. <br /> . �0.14 of-E USE: APPLICATION <br /> (For Non-Transferable, Re vocable;'Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for apermittoconstructand/or install the work,hereindescribed.This application is r <br /> made in compliance wit San Joaquin County O durance No. 1&62 and the.rules and regulations-of the San Joaq in LocgIk District. <br /> Exact Site Address © City/Town J <br /> Owner's Name Zee.. 1 .. '„ Phone <br /> Address 4' city- <br /> �f <br /> Gontractor's Name License# Business Phone <br /> Contractor's Address <br /> IN Ft3 - Emergency Phone ^£ Lt <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No W <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 IQel t Other <br /> Property Line 10 Private Domestic Well �t-Public Domestic Well <br /> INTENDED USE n TYPE OF WELL <br /> 1:1 CABLE TOOL Dia. of Well Excavation_ zl GPGGi <br /> 11 INDUSTRIAL `� <br /> 9 p MESTIC/PRIVATE ®'6-RiLLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of.Casing <br /> ❑ IRRIGATION <br /> ❑,GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION i! M-<0TARY Type of Grout ���� 11,��01r <br /> 00 <br /> ❑ DISPOSAL I 11 OTHER Other Information ✓ / � <br /> ❑ GEOPHYSICAL /Surfac S Installed By: <br /> f �k <br /> PUMP INSTALLATION: i� Contractor � - _ - <br /> Type of Pump.��iH.P. <br /> PUMP REPLACEMENT: ❑ State Work DO,, <br /> PUMP REPAIR: 11 State Work Do eIf <br /> 00 <br /> DESTRUCTION OF WELL: y Well Diameter —Approxi Depth <br /> it Describe Material and Procedure <br /> Cy <br /> ii <br /> I hereby certify that 1 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 thew ork 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 ollsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I 11 f a tin ctlon prior to grouting and a final Inspection. <br /> Signed X ':. ..Title: J .Dale:,. <br /> _ (Draw Plot Plan on Reve a Side) <br /> I <br /> } <br /> - FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ByLLL===JJJ eC� Date Orr <br /> Additional Comments: <br /> ase 11 out In pectlon —,Phase III Final In <br /> Date. <br /> Inspection By 7, c® Date <br /> Inspection By = <br /> J � i <br /> i <br /> Fee Is Due: 0'ANNUALLY1 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January'31 ❑ July 1 8 Reoeiv REMIT <br /> uIy 31 <br /> BASE EXPLANATION _ BILLING REMITTANCE $ AMOUNT DUE 1! CHECKED <br /> DATE "-'I"' DATE REMITTED AMOUNT <br /> FEELESS <br /> 11 <br /> PRORATION it _ <br /> PLUS r <br /> PENALTY 1 ., <br /> OTHER <br /> ii <br /> OTHER <br /> 10 <br /> Received by - '•Date ReceiphNo. Permit No. -'I suan a-Date Mailed Delivered <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bot 2409 STOCKTON,CA 95201 <br /> II __ <br />