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_ I <br /> -� Applicaiioris'111Liti Be=Rrocessed when Submitted <br /> { <br /> FOR'OFFICE USE: <br /> (For Non-Transferable, Revocable,5uspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) 9 <br /> Application is hereby made tothe San Joaquin Local Health District ape a rules and regulations ofthe San Joaquin Local <br /> HealdthTDistCt <br /> made in compliance with n Jo q <br /> In ounty O ina Ic City/Town ( <br /> Exact Site Address o - Phone _27 <br /> Owner's Name City .License# lr7 <br /> Address L Business Phone `Z <br /> � y <br /> Contractor's Name � Emergency Phone <br /> Contractor's AddressYes- No <br /> M Is Certificate of Workman's Compensation'lnsurance on File With SJLHD. ❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION 13 WELL ABANDONMENT <br /> OTHER 13 PUMP INSTALLATION El PUMP REPAiR❑ <br /> LACEMENT❑ es V Pit Privy <br /> i REr Sewer Lines iOther 1 <br /> DISTANCE TO NEAREST: Septic Tank Q Cesspool/ epage Pit <br /> Sewage Disp���e <br /> lpublic Domestic Well -� <br /> f Property Line ! � Private Domestic Well 0 <br /> TYPE OF WELL . <br /> INTENDED USE Dia. of Well Excavation <br /> 1:1 INDUSTRIAL ❑ CABLE TOOL <br /> 11 DRILLED Dia- o Well Casing <br /> DOMESTIC/PRIVATE C3 .DRIVEN Gauge o Casing <br /> 4 ❑ DOMESTIC/PUBLIC GRAVEL PACK Depth of Grout Seal <br /> 11 IRRIGATION <br /> I ROTARY Type of Grout ! �Y- <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information Ae <br /> �7 <br /> j 11DISPOSAL Surface Seal Installed By: <br /> i <br /> ❑ GEOPHYSICAL <br /> I Contractor H.P. <br /> �. PUMP INSTALLATION: Type of Pump <br /> j ❑ State Work Done <br /> PUMP REPLACEMENT: I <br /> PUMP REPAIR: ❑ State Work Done Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure.. <br /> x I hereby certify that I have prepared <br /> regulationsthis <br /> appiicatio the San Joaquin Local 11Healbe th District one in accordance with San Joaquin County <br /> ordinances, state laws, and rule <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance compensation the work for which this penial <br /> ct to <br /> aws of California." <br /> is issued, I shall not employ any person in suce 1 fiesrias to become I certfy thatf ionrthe perfoma ce of the l oris forwh ch this <br /> Contractor's hiring or sub-contracting signature <br /> following:,. <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wI11 for a Groui Ins ction prior to grouting and a final inspection. <br /> DIllate: <br /> Title:Title: "=�� <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> ! FOR DEPARTMENT USE.ONLY <br /> l PHASE I Date I Y d <br /> Application Accepted By <br /> Additional Comments: Phase III Final Inspection <br /> a e Grout inspection �7 Date <br /> Inspectio <br /> Date_ V �� Inspection By <br /> kPER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: Ll ANNUALLY ❑ PER UNIT <br /> REMIT <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE 1- 3 <br /> LESS <br /> i PRORATION <br /> PLUS <br /> PENALTY <br /> M <br /> OTHER <br /> s <br /> OTHER 5 ( 55 <br /> Receipt No. Permit No. <br /> 41^ ssuance ate Mailed Delivered <br /> I Received.by Date 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ( e.. . APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />