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{ - Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTWf!fERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALIYI(~ =: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 compliance with San Joaquin County Ordinanceo. 1862 and the rules and regulations of the San Joaquin Loc I Heal District. <br /> r Exact Site Address S. �I/lnaw City/Town l <br /> t l Phone__gs X22// _ <br /> l Owner's Name <br /> Address City <br /> IM' License Business Phone <br /> Contractor's Name <br /> t Contractor's Address Emergency Phone <br /> f Is Certificate of Workman's Compensation Insurance on File With SJ LF Yes es No <br /> r TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION►J DESTRUCTION❑ <br /> �. WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �� —�" Sewer Lines Pit Privy <br /> Sewage Disposal Fuld1 17F, Cesspool/See eepage Pit Other <br /> Property Line1��- Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation r� <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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 43<4 It &ZC1, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ' PUMP REPLACEMENT: ❑ State Work Done O <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ` Describe Material and Procedure T <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 rulesVand 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 /> r is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> r 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 perso subject to workman's compensation laws of California." <br /> I w, 1 for a Gr t Ins do n to grouting and a final inspection. 7 <br /> '. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverside) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I G Date o v"`e $U <br /> Application Accepted By <br /> Additional Comments: <br /> l Phase 11 Grout Inspection enal In pecten.Inspection <br /> B Date <br /> I Inspection By Date P <br /> 1 <br /> _ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 9 PER SITE ❑ EACH _10-January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHEC <br /> DATE DATE REMITTED AMOU <br /> FEE <br /> 3 y f <br /> LESS <br /> PRORATION <br /> PLUS <br /> c PENALTY <br /> OTHER <br /> OTHER <br /> _ Received by DateReceipt No. Permit No. Issuance Date- Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />