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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOA.OF ICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> k (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> made in compllance:with San Joaquin County Ordinance No`. 1862 and the riles and regulations of the San Joaquin Local Health.District. <br /> 01 <br /> Exact Site Address t . nom �rr I �(1�9 tE Va N E - '� - City/Town -' ,51 p-oK 6 <br /> Owner's Name ' f t Q S F I 1 C Do NN Is Phone T�/ � ���? <br /> F Address ►'li'VE City <br /> Contractor's Name 14; n1N LA " 13x05 License# Business Phone <br /> Contractor's Address ?S_- 106).AIV0!ik19 Emergency Phone _ 'Iny,57— zlk—�;— 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ...__ No <br /> TYPE OF WORK (CHECK): NEW WELIA DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTIa <br /> I 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 q <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 'XDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing P_-N _G <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION t� GRAVEL PACK Depth of Grout Seal �� r <br /> 3 ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> 11 DISPOSAL © OTHER Other Information <br /> r' �< <br /> ❑ GEOPHYSICAL � Surface Seal Installed 8y: y <br /> PUMP INSTALLATION: Contractor <br /> t iType of Pump H.P. <br /> r PUMP REPLACEMENT: ❑ State Work Done <br /> t PUMP REPAIR: ❑ State Work Done r <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, 1 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 /> I will call fora rout Ins ection nor to grouting and a final inspection. <br /> Signed X _ Title: �^y�4A Date: <br /> _ (Draw Plot Plan on Reverse Side) <br /> FOR DEPA77- <br /> T USE ONLY <br /> 6 PHASEI 3 <br /> Application Accepted By "` Date f1 d <br /> ' Additional Comments: <br /> hafiA II Grout Inspection Phase III Final Inspection <br /> i, Inspection Byi ate Inspe5n By Date <br /> Fee Is Due: © ANNUALLY ❑ PER UNI ER SITE ❑ EACH El January r1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ! [�f AMOUNT <br /> FEE <br /> 4, <br /> LESS <br /> PRORATION <br /> - .- PLUS -. <br /> PENALTY <br /> ...BOTHER <br /> k- OTHER f <br /> ` - Received by D to Receipt No. Permit No. Issuance Date Mailed Delivered <br /> A - <br /> APPLICANT—RETURN ALL COPIES TO: ENYIRONMENTAL HEALTH PERMITlSERVICES 1604 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �"` <br />