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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �J <br /> FOR OFFICE USE: APPLICATION <br /> r <br /> P4/44 (For Non-Transferable, Revocable,'Suspendable) PUMP&WELL 1 (� <br /> ENVIRONMENTAL'HEALTH PERMIT l <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY- <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 San Joaquin County Ordinance No, 1862 and the rules and rtions of the San Joaquin Local Health District. <br /> Exact Site Address a� .li eng `�' egul City/Town <br /> Owner's Name . IVi' ow Phone <br /> Address G ' �47/ 'r' City <br /> Contractor's Name /� License#'� rfc .0 Business.Phore'.a <br /> Contractor's Address Emergency Phone '` sr' "•u II 'i7G '¢- <br /> Is Certificate of Workman's Compensation Insurance on Fil ? Yes_X No <br /> TYPE OF WORK (CHECK]: NEW WELL❑r DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> 4 WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ -PUMP REPAIRR <br /> REPLACEMENT❑ <br /> DISTANCE TO,NEAREST: Septic Tank Sewer Lines Pit Privy <br /> I. Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL y <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IIS IRRIGATION ❑ GRAVEL PACK - Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - - Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor m.+ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: ® State Work Done <br /> DESTRUCTION OF WELL: t well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County v <br /> ordinances, state laws, and rules and regulations of-the San Joaquin Local Health District. <br /> ` <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 forwhich this <br /> permit is issued, l shall employ persons�sub'ject.to workman's_compensation laws of California." <br /> I w I call for a Grout lnnsrgec Ion ri r 0'0q r, , nd final inspection. - <br /> A, <br /> Signed Itle: Date: <br /> U. (Draw Plot an on Reverse Side) <br /> ` FOR DEPARTMENT USE ONLY ' <br /> PHASE <br /> Application Accepted By <br /> O Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By 1 fl Date Inspection By <br /> Fee Is Due: 11ANNUALLY [3PER UNIT' ❑ PER SITE ❑ EACH '❑ Janu Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE X EXPLANATION BILLING REMITTAN $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUS - <br /> PENALTY. ' <br /> OTHER <br /> OTHER ,�y1 <br /> i <br /> Received by - Date bReceipt 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 STOCKTON,CA 95201 <br />