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-- <br /> Applications Will Be Processed When Submitted ProperlyCompleted. be5ure Iozagin Iiney a <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY 4 . <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtforapermi toconstructand/orinstall the work.herein described.This application ts <br /> 1 <br /> made in compliance with San Joaquin County r Hance No. 1862 a th les and regulations of the San Joaquin Local Health.District. <br /> f City/Town <br /> Exact Site Address / r - <br /> t Phone <br /> Owner's Name L n <br /> AddressR City <br /> Li cense# Busin s Phone <br /> Contractor's Name ' —' <br /> I Contractor's Address Emergency Phone p,) <br /> I, No IN) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes__X__ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13 RECONDITION 11 DESTRUCTION❑ ti <br /> k WELL CHLORINATION ❑ W-LL ABANDONMENT ❑ OTHER ❑ PUMP—INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENTg <br /> DISTANCE TO NEARE . Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> r <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> K DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> t ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> p ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> El GEOPHYSICAL <br /> PUMP INSTALLATION: <br /> Contractor <br /> iH.P. <br /> Type of Pump 4 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> l ❑ State Work Done <br /> PUMP REPAIR: <br /> Approximate Depth <br /> DESTRUCTION OF WELL. Well Diameter - <br /> Describe Material and Procedure <br /> F ' <br /> l <br /> I hereby certify that I 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 /> Home owner 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ( I will call for a Grout Inspection prior to grouting and a final inspe n. <br /> E Date: / ]{ <br /> Signed X Title: <br /> L (Draw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> Date <br /> Application Accepted By <br /> 9 <br /> Additional Comments: 7 <br /> Phase 11 Grout:lnspection hase III Final Inspection <br /> Date Inspection By Date <br /> Inspection By Z <br /> 4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE El EACH [3January 1 &Received By January 31 ❑ July 1 &Receiv REMIT <br /> uIy 31 <br /> - BASE EXPLANATION BILLING REMITTANCE $ -AMOUNT DUE CHECKED <br /> r <br /> DATE DATE REMITTED AMOUNT <br /> r <br /> r FEE `AS <br /> LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY <br /> OTHER <br /> e <br /> OTHER <br /> ��] r'' <br /> Received by - Date Receipt NoPermitNo. issuance Oat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.RAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95YOt <br />