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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR{OFFIC�USE: F, l il�PPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL 4 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) . - "ILID <br /> w� WT�Q IALITY <br /> i Application is hereby made to the San Joaquin Local Health District fora per to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cou ty Ordinance No. 1862 and the'rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address t10 City/Town- <br /> Owner's Name LJ <br /> 1.L Phone <br /> Address City - <br /> Contractor's Name k)w/1 <br /> License#.Il3 7i� Business Phone' <br /> Contractor's Address c2[ K-a 1 11 :Emergency Phone . - 1, 7 ..N� 0 _- <br /> Is Certificate of Workman's Compensation Insurance ol File With SJLHD? Yes A No j <br /> ( TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN D RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM f <br /> REPLACEMENT❑ I <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> f.IRRIGATION 0 GRAVEL PACK Depth of Grout Seal <br /> ❑ _CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By:' <br /> PUMP INSTALLATION: Contractor_ &_L <br /> Type of Pump 7774 k- 1 4 4 Z23 H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done t` <br /> PUMP REPAIR: State Work DoneE ` ddoop- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depthff� <br /> Describe Material and Procedure " r <br /> } <br /> I hereby certify that I have prepared this application and that the work will be done in accprdance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, <br /> 4 <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, 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 sighature certifies the following:"I certify that in the performance of theork forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />,. �, I 'l l call for a Grout tnspectlo `rior o tiuti nd a Inal inspection. �._,,,.�,.• _ „�„.':� . . <br /> Signed Date: / <br /> A.� {Draw Plot PI on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI � � Q 1 - <br /> Application Accepted By rt �� Date U ~I�� r� <br /> Additional Comments: f <br /> Phase 11 Grout Inspection asp,III F' <br /> Inspection By ! Date Inspection B <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE 1:1 EACH- 11J 1 &Received anuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE.. $ AMOUNT DUE CHECKED <br /> DATEit DATE REMITTED AMOUNT <br /> FEE �xr (AJ e, 1 <br /> LESS } <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date F Receipt No. Permit No. :_ Iss nce Dat _ Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON-,CA 95201 , <br />