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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applic`ation;­ <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> r� <br /> COMPLETE IN TRIPLICATE WATER QUALITY F <br /> Application ishereb made to the San Joaquin Local Health Distridt'fo.ra permitto Construct and/orinstall thework herein described.This application is <br /> made in compli It n Joa nn ou.n�Ordinance No. 1862 and the rules and re Mations of tfie San Joa in Local Health District. <br /> Exact Site Addres� 1 T!t `050 EIC Towri �'��� Al <br /> Owner's Name <br /> 4,e Al T A AAA C` - t Phone <br /> Address . r, .r" e ,t< City <br /> Contractor's Name �� �,�� �G�`l : Licenser# Business PhoneA16 A/ <br /> Contractor's Address <:�T�AJ ,.:-Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No <br /> TYPE OF WORK (CHECK): ' NEW WELL❑ DEEPEN ❑ :" RECONDITION-0 DESTRUCTION I ` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ � t <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 r I C J I <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 Type of Grout <br /> ❑ DISPOSAL ❑ OTHER J Other Information YL IF, t W! <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ___ C'_L4UAz <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 "' pr imate <br /> r <br /> Des c 'b� a Materia and Proced <br /> I hereby certify that I have prepared this application and that the work will be done in a eordanc ith 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." <br /> Contractor's hiring or sub-dontracting signature certifies the following:"I certify that in the performance of the work forwhich this J� <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." t <br /> I will far a Grout Insp cti n prior to grouting and a final inspection <br /> � <br /> S ned .Title: Date: <br /> (Draw Plot <br /> anon Reverse Side) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ln Dale(!- � <br /> Application Accepted <br /> � <br /> Additional Comments: - <br /> Phase 11 Grout Inspection h s RIS Final Inspection ' <br /> Inspection By Date Inspection.syI NJ <br /> ate <br /> -�- <br /> Fee Is due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH- ❑ldanuary 1 &FR'eceived By January 31 - ❑ July 1 &Received By July 31 <br /> REMIT <br /> E <br /> BILLING k REMITTANCE_ <br /> -'BASE � EXPLANATION - }`• -- - � AMOUNT DUE CHECKED <br /> DATE. DATE REMITTED.. AMOUNT <br /> a <br /> FEE <br /> LESS <br /> PRORATION <br /> 4 <br /> PLUS - i e� <br /> PENALTY <br /> 4 . <br /> it OTHER O - <br />! s jJ <br /> a. 'T' OTHER <br /> C3 P V <br /> ..Received=by ate I .,_ - Receipt No.' .Permit No." I Issuance Date Mailed Delivere&_ <br /> . _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />