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` Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I f E <br /> FOR OFFICE USE: APPLICATION - <br /> (Far Non-Transferable, Revocable, Suspendable) <br /> . = L. PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> rill j e <br /> (COMPLET LIGATE) WATER QUALITY I. <br /> Appficafionishereby made tothe San Joaquin Local Health District for apermit toconstruct and/or install the work.herein described. <br /> Thisapplicationis <br /> r <br /> made in compliance with a a uin Cou finance No 1862 an Ah rules and regulations of the San Jo � Lo a�e th District. <br /> Exact Site Address Y 44 City/Town <br /> {f I <br /> Owner's Name /, ' / Phone ! <br /> Address City IM <br /> Contractor's Name �' *� License# Business Phone <br /> I Contractor's Addressr /Erriergency Phone IM <br /> j � 1 <br /> Is Certificate of Workman's Compensation Insur a on File With SJL/HD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION[] Ip <br />` WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 91`� PUMP REPAIR❑ <br /> REPLACEMENT❑ _ - •_- 1 <br /> DISTANCE TO NEAREST: Septic Tankr " .'Sewer Lines- 252 Pit Privy a <br /> f Sewage Disposal Field ._ Cesspool/Seepage.P.it .1641Other <br /> Property Lirie'10 .— Private Domestic Well Public Domestic Well /z/4J'1,e <br /> INTENDED USE TYPE OF WELL <br /> ❑,INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ry i <br /> t OMESTIC/PRIVATE '- . ["ILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC .. . .❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION'S ❑ GRAVEL PACK Depth of Grout Seal _ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL0 OTHER Other Information <br /> 11 GEOPHYSICAL ` surface Se I Iled By: <br /> ( PUMP INSTALLATION: Contractor m s Q_ <br /> { Type of Pump 14f H.P. !. <br /> PUMP REPLACEMENT: 11State Work Done �A1- <br /> PUMP REPAIR: y ❑ State Work Done Jp <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure IM <br /> F .Ip <br /> f i <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaqin Gounfy <br /> ordinances, state.laws, and rules`and regulations of the San Joaquin Local Health District. ; _. 0 . <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof'thework for which'this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> i <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 /> a to a r spectian prior,to grouting and a final inspection. 9� <br /> Signed itle: Date: y <br /> - ( (Draw Plot Plan on Reverse ide) I� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By G ate <br /> I <br /> Additional Comments: � <br /> ' }Pha a 11 Groutilnspection Ph a III Final Inspection <br /> Inspection By Date Inspection B}J/ Date 'I J <br /> t 1 <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT tq PER SITE ❑ EAGH ❑ January 1 &Received B January ❑ July 1 &.Received By July 31 <br /> REMIT. <br /> I 'BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE f CHECKED <br /> [. DATE DATE REMITTED AMOUNT <br /> FEE <br /> I LESS <br /> PRORATION li <br /> PLUS <br /> PENALTY <br /> x OTHER <br /> OTHER F • <br /> Received by - Date -- Receipt No, Permit No. Issuance DateMailed Delivered <br /> f -APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2909 STOCKTON,CA 95201 <br />