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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR or-PnG-USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> 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 a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address -3-4 7 Ti 'I"-°_ City/Town '1�nw�-�-� <br /> A - I <br /> Owner's Name C/ ,�t C 4 n Phone P2_ 3 7 V L <br /> Address City <br /> Contractor's Name License# Business Phone �4 <br /> Contractor's Address Emergency Phone y <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_. No _-,,,__X,_____,_ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PU.MP INSTALLATION PUMP REPAIR 13REPLACEMENT❑ I /1�C 1 <br /> DISTANCE TO NEAREST: Septic Tank Ia Sewer Lines �" " Pit Privy <br /> ! Sewage Disposal Field S d Cesspool/Seepage Pit Other <br /> Property Line 4a d Private Domestic Well yD0 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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information h <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Oe-,q-e r- <br /> Type of Pump H.P. -4 1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <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. U g <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," x <br /> a <br /> I wil a fora ut In etion prior to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i <br /> Application Accepted By ��� Date <br /> Additional Comments: <br /> Ph se II Grout Inspection Ph a Final Inspection <br /> Inspection By Date Inspection By Date �� <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ' <br /> REM iT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION HECKED <br /> DATE DATE REMITTED AMOUNT DUE AMOUNT t <br /> C <br /> FEE � <br /> LESS <br /> PRORATION ! <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER - - -- f <br /> 44 <br /> Received by Date Receipt No. Permit No. Issuance Date Marled Delivered A <br /> APPLICANT—RETURN ALL COPIES TO-.�..ENYIRONMENTAL HEALTH PERMINSERVICES, .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />