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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f %"fioFFICE USE: APPLICATION <br /> 4 <br /> (For Non-Translerable, Revocable,Suspendable) <br /> ENVIRONMENTAL,HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE)�3j77l'7_.rs'. "moo :WATER QUALITY 4y/�AJ, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with•Sa Joaquin.0 unt Ordin ncQ N . 186 and the les and regu t, f Sa in'Cocal Health is 'Ct. <br /> Exact Site Address J' y City/ <br /> Owner's Name Phone <br /> Address I;. City 100 tr_e; <br /> } Contractor's Name y Ice se# 9nY Busi ess Phone_ F:5 M/ " 7 � <br /> Contractor's Address Emergency Phone - Zdil­i�_ 2e <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIDW <br /> REPLACEMENT❑ 4. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy w <br /> Sewage Disposal-etield Cesspool/Seepage Pit Other <br /> Property Line '\'. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing {a <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> OIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 4� <br /> ❑ DISPOSAL - ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / H.P. n' <br /> PUMP REPLACEMENT: ❑ State Work Dane .r <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ? <br /> Describe Material and Procedure <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. <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, 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 /> k — <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." p <br /> I I will I for a ro nsp$c ion prior to grouting and a final inspection. <br /> Signed X _ ` - <br /> 9 Title: - Dale: <br /> (Draw Plot Plan on-Reverse Side) <br /> FOR DEPARTMENT USE ONLY--- <br /> PHASE I <br /> NLY"'" -- <br /> PHASEI <br /> Application Accepted By Dated <br /> t <br /> Additional Comments: <br /> r Phas Grout Inspection - - [!base III Final Inspection <br /> Inspection By Dateg Inspection pate — <br /> r <br /> Fee Is Due: ❑ ANNUALLY �. '❑ PER UNIT` ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> _ REMIT <br /> Y BASE­ EXPLANATION BILLING-- =REMITTANCE - --• -$- "' AMOUNTDUE CHECKED <br /> DATE DATE y REMITTED AMOUNT <br /> FEE cam- <br /> ", LESS Y'} G <br /> PRORATION Y <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> Ap <br /> „ Received by Date Receipt No Permit No. lasdance Okla Mailed D ered <br /> .'' APPLICANT--RETURN ALL COPIES TO;;_.ENVIRONMENTAL HEALTH PIER MIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />