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A p ii coonsWill Be P og �d Wh-e i'tubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: AUG 2 APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> SAN HEALTH DS, �f LOCAL ff RONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with a,.g Joa 0 my Ord}nanc�Nq�62 and the rules and regulations of the Sa�oaa uin Loca ea�District. <br /> Exact Site Address 25 C �?v j7 Y City/Town <br /> Owner's Name 7- Phone 'T 77 " <br /> d 91 City— <br /> Contractor's <br /> it <br /> Coatractor's Name' License#) �°�"� 9 Business Phone <br /> Contractor's Address �ZJ -S�Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes c_� No O <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <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 ,may <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation J <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 <br /> © GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAiR: V4tate Work Don <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 /> Home owner 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 hirin or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit i 7--ishall emp y pe ons subject to workman's compen n laws of California." <br /> I w' c r t Inspe 1 n pri r to gtouting and a final inspecti . <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Dat <br /> Additional Comments: <br /> Phase II Grout Inspection i 06 Phase III Final Inspection <br /> Inspection By Date I ction By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PERS E ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECK <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE • f .S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7Qe,. � <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 />