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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F R OFFICE USE: - - APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ' <br /> ENVIRONMENTAL HEALTH PERMITPUMP&WELL ? <br /> a <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Q <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or instal I the work.herein described.This application is J o <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joa uin Local Health District. <br /> Exact Site Address <br /> ` l 6--� City/Town �.t,s <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name14 ) 670Y License#��G_ Business Phone&:374 ,� 7 4 <br /> Contractor's Address Emergency Phone ' <br /> Is Certificate of Workman's ompensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN ❑ RECONDITION❑ DESTRUCTIONO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewef,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 ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑-IRRIGATION ""' _ _'❑ GRAVEL PACK r--Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION _ �❑ ROTARY Type of Grout k _' <br /> _ E- <br /> ❑ DISPOSAL r}€; - 13 OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> -TY of-Pump - — - ` �H:P: `--- n <br /> PUMP REPLACEMENT: M ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Dpepthh <br /> Describe Materia and Procedurei 7�E�r 6ccazy _F <br /> I hereby certify that I have prepared this app ication and thft the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health­District7-w—___. <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t <br /> I will call for a Grout Inspectiortiprior to grouting and a final inspection. <br /> Signed X Title: Dale: I_o <br /> (Draw Plot Plan on Reverse Side) # a <br /> FO DEPARTMENT USE ONLY <br /> PHASE y" <br /> Application Accepted By <br /> Additional Comments: ` <br /> Phase II Grout Inspection Phase III Final Inspection t <br /> Inspection By Date Inspection By Date I <br /> Fee Is Due: ❑ 'ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ i <br /> BASE EXPLANATION D AMOUNT DUE CHECKED <br /> DATE DATE REMITTE <br /> AMOUNT I <br /> FEE `13 t e) r + <br /> r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 11 <br /> Received by Date Receipt No. :_Permit No Issuance Date Mailed Delivered <br /> ,�.. APPCFGANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES n 601 E:tiAZELTON AVE.,P.O.Is <br /> 2009 STOCKTON,CA 95201 _Q <br />