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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> j (COMPLETE IN TRIPLICATE) WATER QUALITY :R <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 wit an .oaquin County Ordinance No, 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exactf Site Addressy ��• JaJ " ` <br /> City/Town _Z .4,1, <br /> Owner's Name -/�� d I li/V ' >VIA Phone 0 <br /> Address YrC=1;a*, r * city. <br /> Contractor's Name 71:0. <br /> , / ., � I" <br /> `': - s ti _ Phone-' <br /> +�/ �_ P1�crO - License#c9�� f Business <br /> Contractor's Address iyi 1001)' B a 'Emergency Phone 6'1;;, <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? _ Yes VIA No <br /> TYPE OF WORK (CHECK): NEW WELL 13DEEPEN ❑ --- RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 <br /> REPLACEMENT 99 <br /> I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t, <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 /> — <br /> 9 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC _ ❑ DRIVEN _ Y Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal . <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL t ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seat lnstalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpr7 H1.P. <br /> PUMP REPLACEMENT: ® State Work Done - <br /> PUMP REPAIR: ❑ StateWork Done <br /> e DESTRUCTION OF WELL: Well Diameter """ Approximate Depth <br /> _ r <br /> k 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. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued,-1 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." <br /> I <br /> I will all for a- tout I pection prior to grouting and a final inspection. f� �t <br /> I Signed X Title: Date: _ <br /> (Draw Plot Plan on Reverse Side) <br /> 5 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 - <br /> Application Accepted By "� --- Date "S S-t <br /> Additional Comments: <br /> i <br /> Phase II Grout Inspection Kase III Final Inspection <br /> f :Inspection By- Date Inspection Date ✓ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'EACH ❑ January` ceived,By January 31 ❑ July 1 &Received By July 31 <br /> _ - - - REMIT <br /> BASE EXPLANATION BILLING .REMITTANCE: $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT. <br /> F FEE` Q r <br /> I - <br /> 1 LESS. .. ... . <br /> r PRORATION <br /> PLUS <br /> PENALTY i <br /> E <br /> OTHER <br /> I OTHER _ <br /> I <br /> m <br /> C i l 11 AL3 5{o F <br /> Received by Die— - Receipt No. - -- Permit No. - - -- Issuance-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 />