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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR oFFtcE USE: l APPLICATION <br /> Far Non-Transferable; Revocable,Sus endable <br /> ENVIRONMENTAL HEALTH PERMIT PUMP PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora 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 and regula Lo ofJ`ie San Joaquiryl-ocal a Ith District. <br /> Exact Site Address l.'�S + "t.f Seew, 4141:9 �iE. if yfio-wn L�e[�9 <br /> Owner's Name <br /> Address A-✓i l�sa� -_ City <br /> .t <br /> Contractor's Name License#d, 27L�Business Phone7` <br /> Contractor's Address all . Emergency Phone i <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ® ? <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION,® PUMP REPAIR❑ 1 <br /> REPLACEMENT Q <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines t 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 _ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �y <br /> 0 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 <br /> ❑ GEOPHYSICAL Surface Seal I t led By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: C1State Work Dane I <br /> a <br /> P6%A#R: �,State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth gg <br /> Describe Material and Procedure <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> a . <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. o 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 q <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:"1 certify that in the performance of the work forwhich this is <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ,I vilffil call for a Grout Inspec"o pr' r o aro ting an final inspection. _ <br /> Signed X Itle: S"�"t;f Date: <br /> (Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI 1� Si <br /> Application Accepted By t / Date-L <br /> Additional Comments: <br /> Phase II Grout Inspection ehase III Final InspectionF, v <br /> Inspection By Date Inspection By ate <br /> logs <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 J <br /> - a ' 1. BILLING REMITTANCE $ REMIT <br /> BASEEXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ' Ir}st-1� u <br /> LESS i ��tl <br />, PRORATION / <br /> PLUS 4 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l - - <br /> a �3 <br /> Received by Date Receipt No. Permit No. Is uanc Date Mailed Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />