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Applications Will Be Processed When Submitted Properly Completed BeSure tosign rn <br /> FO .FEI,CE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> istrictfora permit construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health D { }� <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San-Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> 3 6- <br /> Owner's Name sem/ r a <br /> l/ . �t� City <br /> Address ��+11 <br /> Contractor's Name LicenseAe� Busine Phone <br /> Emergency Phone -3 f <br /> Contractor's Address � V <br /> is Certificate of Workman's Compensation Insurance on t=ile With SJLHD? Yes 4__ No <br /> TYPE OFNVORK (CHECK): NEW WELL9'rDEEPEN 11 RECONDITION DESTRUCTION <br /> ❑ S <br /> WELL 1.CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13PUMP INSTALLATION ZL----13UMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other , <br /> 4 �'a Public Domestic Well I <br /> I Property Line Private Domestic Well �..� <br /> INTENDED USE TYPE OF WELL ' A/ { <br /> ❑ CABLE TOOL Dia':of Well Excavation i <br /> © INDUSTRIAL // -4) <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11 DRIVEN <br /> ❑ DOMESTIC/PUBLIC Gauge of Casing ® P 3 <br /> 13 GRAVEL PACK Depth th of <br /> Grout Seal <br /> 11IRRIGATION <br /> ElCATHODIC PROTECTION {�OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information i <br /> ❑ GEOPHYSICAL01-1 Surface Seal Inst Iled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> - Describe Material and Procedure <br /> 1 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 forwhich 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 /> r Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.' <br /> 9 I will 11 for a Grout Inspection prior to gr uting and a final inspection. d <br /> Title: <br /> Date: _zo// 7_ <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Dat���� <br /> Application Accepted B <br /> Additional Comments: p Final In <br /> Phas II Grout inspectio J fieCHOr�z <br /> Inspection By <br /> ate Inspection B Date <br /> Fee' Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ ,anuary 1 &Received By January 31 ❑ July 1 &Receive�dEB/y}July 31 <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS l <br /> PRORATION 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t ' <br /> r OTHER <br /> Receipt No. Permit No- �y I suanc Date Mailed Delivered <br /> Received by ' 1601 E.HAZELTON AVE..P.D.Box 2004 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICE - <br />