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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> FOR OFFICE USE: - �. <br /> t APPLICATION <br /> tok*,�6�'4 • (For Non-Transferable, Revocable, Suspendable) <br /> �. <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPI-ETE IN TRIPLICATE ..,-�- WATER QUALITY <br /> 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 Ordinance No. 1862 and the rules and regulations of the San Joaquin Local,Health Distric <br /> Exact Site Address O �� _ City/Town �rr� <br /> Owner's Name P*.C� e. ?Vpg-44pnir 1 <br /> Address Phone <br /> City <br /> Contractor's Name License# 7 Business Phone <br /> u Contractor's Address mergency Phone <br /> .. L", rtificate of Workman's Compensation Insurance on File With SJ� D? Yes No <br /> TYPE-OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRER <br /> i REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �. <br /> Sewage Disposal Field Cess ool/Seepage Pit Other <br /> ^'- Property Line Private Domestic Wel! Public Domestic Well <br /> INTENDED USE~ TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLEDt <br /> 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 <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor __SS <br /> Type of Pump H.P. �� o <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done aiw_J e if <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s g <br /> I hereby certify that f 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 he 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 orsub-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 w'l call for a Grout Inspection p 'o to ou Ing and.a final inspection. <br /> Signed X Itle: Date: <br /> (Draw Plot an on Reverse Side) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I , <br /> Application Accepted By_k" <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ill Final Inspeo ' <br /> 5L <br /> Inspection By pate Inspection By_ /O an <br /> -fid p <br /> ( . <br /> Fee Is Due: ❑ ANNUALLY ❑ PER+UNIT1 ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar . <br /> Y 31July 1 Received By July 31. <br /> BASE EXPLANATION BILLING , REMITTANCE $ w REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEEtil T <br /> O AMOUNT <br /> y� <br /> LESS „ <br /> PRORATION <br /> ,PLUS <br /> { <br /> PENALTY <br /> OTHER. <br /> OTHER <br /> Z <br /> Received by Date Receipt No. Permit No. Is uance 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 />