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Applicatlons Will Be..Processed When Submitted Properly omp e e <br /> FOR OFFICE USE: APPLICATION <br /> (b (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> LocalHealthDistrictforapermittocons[ructand/orinstalltheworkhereindescribed.Thisapplicationis <br /> ApplicatianisherebymadetotheSanJoaquin <br /> i made in compliance with San Joaquin County Or inance N . 1 nd the rules and regulations of the San Jo n Lo al Health District. <br /> v ! City/Town <br /> I Exact Site Address <br /> Phone <br /> Owner's Name <br /> Address <br /> s�,<3 Pte,-s�►•a -S cR.4�a 3 _city �... <br />' Contractors Name �' �` License# .� Business Phone ' <br /> I Contractor's Address Emergency Phone .--.._ <br /> I No t. <br /> k Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes l <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> r WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER [I PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ Y <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 /> 5 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> i <br /> C3 IRRIGATION [I GRAVELPACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ` ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor F �s <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done '11' 0 21 <br /> PUMP FfElhAft State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f 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 /> I 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 forwhich this <br /> permit is.issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection In r g utin nd a ' al inspection. <br /> le: _ � Date: <br /> Signed X <br /> (Draw Plot non Reverse Side) <br /> FOR DEPARTMENT USE ONLY i <br /> 1 1 l <br /> PHASE I Date <br /> Application Accepted By <br /> I <br /> Additional Comments: <br /> Phase Ill Fin/I Inspection <br /> Phase II Grout Inspection Ciy <br /> Inspection By <br /> Date <br /> Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> i BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> i BASE ' EXPLANATION DATE DATE REMITTED AMOUNT <br /> 0 <br /> FEES <br /> r <br /> LESS <br /> } PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> Received by Date - Receipt No. <br /> Permit No Iss cc ate Mailed Delivered - <br /> 1601 E.HAZELTON AVE.,P.O.Boa 21)09 STOCKTON,CA 95201 <br /> ., APPLICANT—RETURN ALL COPIES Tp: ENVIRONMENTAL'HEALTH PERMIT/SERVICES _ -" - <br />