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2U, <br /> ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application,'F=OR OFFAPPLICATION <br /> k (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Joaquin County Ord17 No. 1 and the r <br /> d regulations of the San J uin Local H alth District, <br /> Exact Site Address <br /> r� City/Town , <br /> Owner's Namer✓lHf/ C s <br /> I Address Phone <br /> Contractor's Name me <br /> # - <br /> Business Phone <br /> Contractor's Address ency Phone <br /> Is Certificate of Workman's Compensationurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 No <br /> ❑ \ <br /> I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines _ Pit Privy � <br /> Sewage Disposal Field Cesspool/Seepage Pit1 <br /> Other <br /> Property Line Private Domestic WellPublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> h ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation �r <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 7 <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> ❑ IRRIGATIONGRAVEL PACK Depth of Grout Seal <br /> 11 ` <br /> CATHODIC PROTECTION ROTARY <br /> Type of Grout _0� <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �t <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor — <br /> T Type of Pump ,L~ H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter { <br /> 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 /> 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 will all fora grout Insp tion for to grouting and a final inspeti. n. <br /> Signed X �`r Title: _11L, % — a 6J -, Ste• <br /> 7 <br /> (Draw Plot Plan on R verse Sidej Date: <br /> PHASE I , FOR DEPARTMENT USE.ONLY <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phas II Grout Inspection <br /> Inspection By T., �i� Phase III Final Inspection <br /> � Date !��f/ 8/ Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT <br /> ❑ PER SITE ❑ EACH ❑ 1 &R <br /> January eceived By January 31 <br /> . El July 1 8 Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT .� <br /> LESS <br /> PRORATIONr <br /> PLUS JYV ' G s! /PJ► � *!_a+ ` <br /> PENALTY <br /> OTHER G� 4 elw-4 _e 'oG r I` <br /> OTHER <br /> Al2 - <br /> Received by Date Receipt No. Permit No. <br /> Issuance Date _Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,PR!,c$X TAOt� -STOCKTON,CA 9520 <br />