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+ Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFI'll USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> in Local Health Districtfora permit construct and/or install thework herein described.This application is <br /> Application is hereby madeto theSan Joaqu <br /> made in compliance with San Joaquin County Ordi ance No. 1W2 and the,rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address x IIIIIIc <br /> Owner's Name <br /> Phone �— <br /> . ;; , •City cam. o <br /> Address �"� / Oa <br /> I Contractor's Name K <br /> hone <br /> License# Business P <br /> _( 7 <br /> D -= Emergency Phone <br /> F Contractor's Address I <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes No <br /> —�, <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION ❑ PUMP REP <br /> AIR❑ _! L <br /> REPLACEMENT❑ ) <br /> DISTANCE TO NEAREST: Septic Tank f5ewer Lines/) Pit Privy — <br /> Sewage Disposal Fi7ld Sn -�_.� Cesspool/Seepage Pit — Other <br /> /� <br /> Property Line Private Domestic Well Public Domestic Well —�-- <br /> INTENDED USETYPE OF WELL r1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation rr <br /> ❑ E] DRILLED Dia. of Well Casing — <br /> 11P—(DOMESTIC/PRIVATE / <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> El IRRIGATION GRAVELPACK Depth of Grout Seal <br /> 11CATHODIC PROTECTION ROTARY Type of Grout <br /> 13DISPOSAL ❑ OTHER Other Information �^ <br /> i <br /> 13 GEOPHYSICAL Surface Seal installed By: r <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <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"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 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 II call f r a t In.sie 'or+ or to grouting and a final inspection. <br /> Title: x�"F" Date: r <br /> Signed X l <br /> (Draw Plot Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I O <br /> pate <br /> Application Accepted By <br /> Additional Comments: <br /> I Grout Inspection P i all Inspection <br /> Date 494/ <br /> Inspection <br /> R l _ Inspection By Date <br /> Fee IS Due: ❑ NNUALLY ❑ PER UNIT ' ❑ PER SITE -❑ EACH - ❑ January i & ived By January 31 ❑ July 1 &Receivend By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 1� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> P�ilN O_ I suance ate Mailed Delivered <br /> Received by Date Receipt No. •- <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 7601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />