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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION xf <br /> (For Non-Transferable, Revocable,Suspendable) pUMp&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 3 <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install the work herein described.,This application is <br /> made'h compliance with.,Crl <br /> SanJoaquin County Ordinance No.1$62 an the rules and regulations of the San Joaquin Local Health District. <br /> Exact.Site Address 0 C Ql 5 g City/Town <br /> Phone <br /> Ownez's Name <br /> '/a9o21 <br /> Address <br /> � �. �t Q.rL �G�2E City i <br /> � <br /> Contractor's Name License# �����✓� Business Phone 63� .. .� <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes DESTRUCTION❑ <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DE `f { <br /> WELL CHLORINATION El WELL ABANDONMENT C1OTHER 1:1 PUMP INSTALLATION ❑ PUMP REPAIR 13 1 <br /> REPLACEMENT❑ i } <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field /001 Cesspool/Seepage Pit Other # <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL . // <br /> El INDUSTRIAL - 13 CABLE TOOL Dia. of Well Excavation / j <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION �{GRAVEL PACK Depth of Grout Seal <br /> i <br /> ❑ CATHODIC PROTECTION }al ROTARY Type of Grout <br /> 11 DISPOSAL <br /> 11 OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: i <br />' PUMP INSTALLATION: Contractor <br /> Type of Pump WP' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 <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 Il for a Grout Inspects n r to grouting and a sinal inspection. `�%� <br /> Signed X <br /> Title: Dale: � //ZF...2 <br /> (Draw PI Plan on Revers Side} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I d- 3 9;LApplication Accepted By � Date <br /> Additional Comments <br /> Ph p II ut Inspection _ Phase kl Final Inspection <br /> Inspection By �` Date Z�L Inspection By Date <br /> F. <br /> By <br /> s <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH. ❑ January 1 &Received By January 31 ❑ JuVy 1 &ReceivedREMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> _ DATE DATE REMITTED AMOUNT <br /> i FEE <br /> ! _ <br /> k LESS <br /> PRORATION <br /> r PLUS <br /> I PENALTY <br /> OTHER <br /> I OTHER <br /> 3 <br /> �. ._._Received by .,,. Date Receipt No. Permit o. - Issuance Date-.. - Mailed Delivered <br /> a <br /> -. Box 2009 STOCKTON,CA 95201 <br /> APPLICANT.—RETURN ALL COPIES TO: ' - ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON-AVE_,P.O. — <br />