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a , <br /> Appklctions Will Be Processed When Submitted Properly Completed. Be Sure ToSignThe <br /> AOR 0M- CE USE: APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to 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 w' San Joaquin County OrdinEl.ce N. 1862 nd the rule and lotion f the San J aquinC�al Health District. <br /> ll Cit /Town <br /> Exact Site Address S + <br /> /' C G Phone 7 <br /> Owner's Name C <br /> .. City t <br /> Address ., Z 7 <br /> Contractor's Name License# ,-Z Business Phone <br /> Emergency Phone <br /> Contractor's Address 3-f?�d j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ O <br /> WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION <br /> ❑ PUMP REPAIR❑ <br /> REPLACEMENT[] 0 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Other <br /> Sewage pisposal_Fjield Cesspool/Seepage Pit ----� <br /> Property Line o_it Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL �� <br /> El INDUSTRIAL <br /> 13 CABLE TOOL Dia. of Well Excavation <br /> ' <br /> ❑.DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Q <br /> OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -r— <br /> u IRRIGATION GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> El DISPOSAL ❑ OTHER Other Information01 <br /> ❑ GEOPHYSICAL Surface Seal Installed BY: <br /> 1 PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <br /> y <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 j <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> f 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 Californias <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> ct to workman's compensation laws of California." <br /> permit is issued, I shall employ persons subje `r <br /> I will c r a Grout Ins e on prior to grouting and a final inspection. <br /> I Title: Date: <br /> Signed X _ -c- <br /> ` (Draw Plot Plan on Reverse Side) <br /> F 6 FOR DEPARTMENT USE ONLY <br /> J' <br /> PHASE I <br /> Date <br /> Application Accepted By <br /> Additional Comments: - <br /> II Grout I pectionto a e Ill Fin nspection / <br /> F SJ Inspection By <br /> AV <br /> Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> F BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> ff DATE DATE REMITTED AMOUNT } <br /> FEE 4 It <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> N <br /> OTHER <br /> w Date Receipt No. Pe�rrnA No. - - Issuance Date Mailed Delivered. <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES '7601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 f <br />