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/ Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendabie) PUMP&WELL y t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WAFER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This,application is <br /> made in compliance wJ S In Joaquin 9agnty Ordinance No. 1862—H The rules and regulations of the San oaq`auin Local Health District. <br /> Exact Site Address �f`(( City/Town ' <br /> Phone <br /> Owner's NameA CK i <br /> Address C2ity <br /> Contractor's Name b .. License# 1 2_�&Usiness Phone" � � <br /> Contractor's Addr Emergency Phone- ev\ 44. <br /> Is Certificate of Workman's Compensation Insurance on File With SRECO Yes <br /> OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIONO'- <br /> TYPE <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ `OTHER ❑ PUMP INSTALLATION. PUMP REPAIR❑._ Uv <br /> REPLACEMENT❑ .� I <br /> .t t <br /> DISTANCE TO NEAREST: Septic Tank-, Sewer Lines 1 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line . Private Domestic Wel ' ,Public•Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL "� . t " ❑(CABLE TOOL Dia. of Well Excavation- s <br /> ❑ DOMESTIC/PRIVATEw <br /> ❑ DRILLED Dia. of Well Casing TV q- <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 1,�,:-1GRAVEL PACK Depth Of Grout Seal <br /> 1191 <br /> CATHODIC PROTECTION -9 ARY Type of Grout 9 C� ` <br /> ❑ DISPOSAL ❑ OTHER Other Information s <br /> ❑ GEOPHYSICAL Surface Seal Installed By:., • "; - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> 11 State Work Done I <br /> PUMP REPAIR: ❑ State Work Done cr <br /> DESTRUCTION OF WELL: Well Diameter pproximate epth <br /> Describe Material and Procedure <br /> 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> i <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 /> I l coil for a Grou Ins ection prior to grouting and a final Inspection. Z1, <br /> Si ned X �� � -- .. Title: � � { Date: <br /> Z <br /> 9 � i4 F <br /> (Draw Plot Plan on Reverse Side) <br /> FOR PARTME T USE ONLY <br /> PHASEI <br /> Application Accepted By �Z, °"`` Date t <br /> Additional Comments: <br /> hase 11 Inspection p 1 ase 111 I Inspection �-� `-� <br /> 1 -Inspection By ate f Inspection By e 3 '`,. <br /> ` Fee Is Due. ❑ ANNUALLY ❑ PER UNIT ' ❑ PER SITE - -❑ EACH ❑ January 1 &Received By January 31 —0 July 1 BiReceived 13yiJuly 31 <br /> REMIT <br /> BASE EXPLANATION .BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ir 9 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY F <br /> .LRT- <br /> THER R <br /> OTHER <br /> 4 -6 <br /> Reived by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 <br />