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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;Suspendable) PUMP &WELL <br /> PI <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 0 Of i—•, -T <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 Sn Joaquin County inan No. 1892 and the r} regulations of the San oal u Local Health District. <br /> Exact Site Address � l /' v 1 'City/Town p O UI I <br /> NF1" <br /> Owner's'Name � ltJ � L L � Phone �4 4 -- 71, e� S,I�Pk( <br /> Address City 5za C-A o-A <br /> Contractor's Name License# °' Business Phone= rV <br /> Contractor's Address Emergency Phone i <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): l NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTI N' 41- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ II, <br /> , ,II <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> W <br /> Property Line Private Domestic Well Public Domestic Well <br /> t INTENDED USE l TYPE OF WELL <br /> ❑ INDUSTRIALS ❑ CABLE TOOL Dia. of Well Excavation =- -- ---- <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> l ❑ DOMESTIC/PUBLIC iI ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION l6 ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTIONS ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ji ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL' 'i rface Seal Installed By:, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P._ l <br /> PUMP REPLACEMENT: �� ❑ State Work Done <br /> PUMP REPAIR: I, ❑ State Work Done <br /> DESTRUCTION OF WELL: Well.Diameter Approximate Depth <br /> I� Describe Material and Procedure <br /> 3 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 became 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 inspection. <br /> Signed X ! Title: Date: <br /> (Draw Plot Plan on Reverse Side) P _. <br /> �y FOR DEPARTMENT USE ONLY <br /> PHA /� , <br /> Application iAccepted By Date«�' <br /> Additional Comments: <br /> Phase II Grout Inspection Ahase,it Fit I Inspection <br /> I Inspection By #. --Date ' Inspection By ate <br /> I; <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 1:1 EACH: ❑ January 1 &Received By January 31 ❑ July i &Received By July 31' <br /> ' REMIT <br /> BILLING REMITTANCE $ <br /> BASE" `EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT > <br /> F FEE <br /> LESS <br /> r PRORATION E, <br /> PLUS 3P <br /> PENALTY u' <br /> OTHER <br /> ti OTHERrh <br /> Received by te. - Receipt No. - Permit NW Issuance Date- Mailed Delivered <br /> v APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 r y <br /> • - Ia1J <br />