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Applications Will Be Processed When Su6niitted-Properly Cpinpleted. Be Sure To Sign The Application. <br /> FOR OFFICE USE: � . APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> r At <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ! <br /> Application is hereby made to the SarilJoaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> ,I <br /> made in compliance with S n Joa ui Count g Ordina�ce No. 18 2nd the rules and re ulations of the San Loc H alth District. <br /> Exact Site Address 4 Clat2 ofd ' Gity/Town p7� r <br /> v !I <br /> Owner's Name rse- Phone !/ a <br /> Address _1,S City 4;2b <br /> Contractor's Name 4)4" (,'LrJ License#193" �5`Business Phone L �" <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi,h SJLHD? Yes ! No i <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN El RECONDITION❑ DESTRUCTION El 0) <br /> WELL CHLORINATION 11WELL <br /> ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 7 <br /> REPLACEMENT❑ �� <br /> DISTANCE TO NEAREST: Septic,Tank Sewer Lines 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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> DOMESTIC/PRIVATE 11-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: <br /> PUMP INSTALLATION: Contractor m - ..I <br /> Type of Pump cSu a�p4s a H.P. 0 <br /> PUMP REPLACEMENT: I• ❑ State Work Done f <br /> PUMP 9 State Work Done �^ t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I - - <br /> Describe Material and Procedure _J <br /> I hereby certify that l 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. it <br /> dome owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit I <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." i <br /> Contractor's hiring or subcontracting 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 WJA call for a Grout ins iM o o g ting and a final inspection. <br /> I. I / <br /> Signed it1e: �,+rG';$ Date: <br /> iI. (Draw Pla Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 '9 <br /> Application Accepted By �, Jr� <br /> Dat <br /> Additional Comments: IM <br /> w <br /> Phase II Grout Inspection � Phase I11 Final Inspection <br /> Inspection By �N Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY l] PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rec ved 8y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> . - BILL#NG REMITTANCE <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ck <br /> LESS <br /> PRORATION, l <br /> PLUS <br /> PENALTY <br /> OTHER I ' <br /> v OTHER <br /> Received by a Date i Receipt No. Permit No. Is uarscekDate _ Mailed Delivered , <br /> APPLICANT—RETURN ALL COPIES,TQ 'L ENVIRONMENTAL HEALTH PERMIT/SERVICES -.1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 9', <br />