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A6 Applications vvrn ow Processed When Submitted Properly Completed. BeSureToSignTheAppltcaaon. <br /> FOR oFl`1cE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <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 in compliance with San Joaquin County Or finance No. 1862 and the rulesiand regulations of the San Joaquin Local Health District. <br /> rf* <br /> Exact Site Address "' L City/Town A(} <br /> Owner's Name 2V Phone B . <br /> Address City e� <br /> Contractor's Name % License#PJ2RJ a Bu iness Phone 3 f< ^i <br /> Contractor's Address U - Emergency Phone 9v <br /> Is Certificate of Workman's Compensa ion Insurance on File With SJLHD? Yes— X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN t11 RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT,K <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED , Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information U, <br /> ❑ GEOPHYSICAL Surface Seal Installed By: Ly <br /> PUMP INSTALLATION: Contractor <br /> e of Pump H.P. <br /> Ty <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 /> 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 F <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w_ ill call for a Grout Inspection prior to grouting and a final inspect' n. <br /> Signed X C u Title: �►.G�Z f.Co Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE I ORD PA <br /> FRTLY <br /> ...,Application Accepted By MENT USE ONDate <br /> Additional Comments: <br /> Phase II Grout nspection P as�f Final Inspection ai <br /> Inspection By Date Inspection By Qate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑1July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7—t 6-s-o J2 <br /> Received by Date Receipt 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 /> • r <br />