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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendabie) PUMP&WELL f <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATERQUALITY +. . <br /> Application is hereby made to the San Joaquin Local Health District fora perAt to construct and/or install the work herein described.This application is <br /> made in compliance with-San J aquin County Ordinance No. 6 and they rules and regulations of the San J uin Local Health District. <br /> . C�r'�' t ,. City/Town I <br /> Exact Site Address <br /> A r <br /> Owner's Name ;� Phone_ ��` 76 <br /> J .City _ <br /> Address �— <br /> Contractor's Name License#,36�l.Z/ Business Phone <br /> Contractor's Address `s .,t���j�� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fite With SJLHD? Yes __ No �1 <br /> TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑ RECONDITION❑ _. DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION-IR PUMP REPAIR[1 r <br /> REPLACEMENT❑ / / k <br /> DISTANCE TO N)rAREST: Septic Tank S�wer Lines_ � Pit Privy 1,14 <br /> Sewage Disposal Fie d_4 Cesspool/Seepge Pit Others <br /> Property Line /p#Private Domestic Well � Public Domestic Wel . ? <br /> INTENDED USE TYPE OF WELL y <br /> ❑,NJDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation—� <br /> Ed DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ED i- EN Gauge of Casing <br /> ❑ IRRIGATION �RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grouter <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL i r Surface Seal Installed By: Z lklae ' <br /> PUMP INSTALLATION: Contractor aw ; <br /> Type of Pump N.P. ) <br /> I � ! t <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ❑ State Work Done I � <br /> PUMP REPAIR: � CA) <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> r <br /> I hereby certify that I have prepared this application and that: the work will be done in accordance with San Joaquin County rA <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. "t <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shall not employ any person in.such manner as tot become subject to workman's compensation laws of California." <br /> t <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance'ot the worli'fo�whichthis <br /> permit is issued, I shall employ persons subject to workman's'compensation laws of California." <br /> I will tail for Grout Inspection prior to g Touting and a final inspection. - <br /> Signed X ' i Title: —�s2 {' +�G ; — Date: <br /> ;(Draw Plat Plan on Reverse Side) <br /> : t ` <br /> FOR DEPARTMENT USE ONLY �� s <br /> I * � <br /> PHASE <br /> z= � <br /> Application Accepted By j Date <br /> 3 F <br /> Additionalnal Comments!- <br /> Ph <br /> omments:Phout inspection inal Ins ectio�n <br /> ateInspection By � <br /> + <br /> f' <br /> Inspet;tion By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN`iT - ❑,PER SITE "❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &'Received By July'31' <br /> IREMIT I <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION " DATE �,I DATE L REMITTED <br /> AMOUNT i <br /> FEE <br /> w.w..-_..-- <br /> LESS @I <br /> PRORATION _ •-,-1 -y _ ~"-' f 3 <br /> *PLUS - ✓ L��: _°' Y Nj <br /> PENALTY _ <br /> OTHER ai <br /> OTHER .f <br /> Received by Date _ Receipt No. .- Permit No. - I suance Date Mailed Delivered <br /> Bax 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT!$ERVICES 1601 E.HAZELTON AVE.,P.O. <br />