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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplicanon. <br /> FOR OFFICE USE: APPLICATION <br /> i00 A, (For Non-Transferable,Revocable,Suspendable) r PUMP&WELL <br /> ENVIRONMENTAL HEALTHPERMIT / <br /> WATER QUALITY ,,.. <br /> (COMPLETE IN TRIPLICATE) T"w•e+e r, <br /> Application is hereby made to the San Joaquin Local Health District for a permit tconstruct a <br /> o ond/or install the worherein described.Th is application'is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the' rules and regulations of the San Joa��uInLocal Health District. <br /> s,.. City/Town `' <br /> Exact`Site Address ` <br /> Phone_ •:.a�.. <br /> Owner's'Name -. City.- . <br /> ..- t <br /> Address ,�� � - <br /> Contractor's Name } License# 1.2. ?Y. "' Business Phone <br /> �, f <br /> Contractor's Address 1 Emergency Phone No <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes a TYPE OF WORK (CHECK): `NEW WELL❑ DEEPEN❑--- RECONDITION❑. ` �DESTRIJCTION❑ _r <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 0 PUMP,REPAIR <br /> REPLACEMENT❑ �_^ _ <br /> DISTANCE TO NEAREST: �Septic Tank <br /> 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 t <br /> ❑ INDUSTRIAL 1:1CABLE TOOL Dia. of Well Excavation <br /> 1:1 DOMESTIC/PRIVATE El DRILLED Dia" of Well Casing <br /> 1:1DOMESTIC/PUBLIC ❑'DRIVEN <br /> "Gauge of Casing ' { <br /> IRRIGATION ;. _ 1:1 GRAVELPACK Depth of-.Grout Seal <br /> 13CATHODIC PROTECTION 11ROTARY Type of Grout F <br /> 11 DISPOSAL " ❑ OTHER "" <br /> Othw-nfoernatiori <br /> Surface Seal Installed 1 <br /> ❑ GEOPHYSICAL _ Z:) t <br /> PUMP INSTALLATION: Contractor ., <br /> l Type of Pump H.P. <br /> PUMP REPLACEMENT: A ❑ State Work.Done <br /> PUMP REPAIR: (0 State Work Done <br /> DESTRUCTION OF WELL: Well Diarrlete� <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San J aquin County <br /> ordinances, state law';and rules-and regulations of the San Joaquin Local Health District. r <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 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 . 1 <br /> I III call.for a Grout Inspection 1 r to gr ting an V final insperi+�on - - i t <br /> tt ills: <br /> Signed <br /> iUr/f�J Date: <br /> L (Draw P1 Plan on Reverse Side) <br /> 4 <br /> i r, FOR DEPARTMENT USE ONLY <br /> r PHASE la ( Od— <br /> Date <br /> Application Accepted By <br /> Additional Comments: ` <br /> —PFiase 11"Grout Inspection . <br /> a se I R-1 p.1 Inspection l0 <br /> I C Inspection By _� Date <br /> Inspection By A Date <br /> Fee IS Due: ❑ ANNUALLY ❑'PER UNIT ❑ PER SITE- EACH ❑ January 1 &Received 0y January 31 July 1 8 Received—REMIT 3Z <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> " BASE - EXPLANATION- -*. DATE -DATE REMITTED s AMOUNT <br /> FEEAA— <br /> LESS <br /> PRORATION , <br /> 4- <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER' <br /> THER -OTHER <br /> i - .Receipt No Permit No. Issua ce D to Mailed De$lvered <br /> Received by '. Date. ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1001 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />