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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR arOICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT ( � — <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora 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 nd egulations of the Sa aquln ocal Health District. <br /> Exact Site Address YC2 City/Towr ,(+...� <br /> Owner's Name 0 12 Phone 0 LIZ <br /> Address City ` r <br /> Contractor's Name License#" y Business Phone 2l.�F .- <br /> Contractor's Address Q I° C i 15WIL16126K. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L----' No <br /> TYPE OF WORK (CHECK): - NEW WELL❑.. DEEPEN ❑ RECONDITION❑ ._ LAI DESTRUCTION,,❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 116 <br /> PUMP INSTALLATION 6--"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 /> ❑ IfjPMTRIAL ❑ CABLE TOOL Dia. of Well.Excavation <br /> kg'DOMESTIC/PRIVATE 17 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 w Surface Seal Inst lied By: <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 ` <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 /> - <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> x 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> or a Grout Inspection prior to grouting and a final inspection. <br /> Signed Title: Dale: 62 :7f <br /> +� <br /> (Draw Plot Plan on Reverse Side) <br /> E <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I s�s%C�"' <br /> Application Accepted By - -- _. . Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph s II Final 9spection2 4e <br /> 8 � <br /> Inspection By Date Inspection By Date <br /> � I <br /> Fee Is Due: C1ANNUALLY ❑ PER UNIT ❑ PER SITE 11EACH 1:1January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DVE CI CHECKED <br /> AMOUNT i <br /> a FEE <br /> LESS <br /> PRORATION <br /> 1 <br /> PLUS 7' r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> Received by - Date - Receipt"No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Boa 2009 STOCKTON,CA 95201 <br /> w <br />