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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. �,[ <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) , PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fo r a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Court O dinance No. 1862 and the rule arg�lations of the San Joaquin Local Health District. <br /> Exact Site Address l�N"t � U� T S' City/Town <br /> Owner's Name r, it CA Phone <br /> Address City <br /> Contractor's Name �/ i=i tit <br /> License# ! 'XTI_ Business Phone /P -ZY�. 1 <br /> Contractor's Address 3 e C7 s' e(L Emergency Ph 'n <br /> e r ,� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No i <br /> TYPE OF WORK (CHECK): NEW WELLAi DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines /V a Pit Privy <br /> Sewage Disposal Field fat?j— _ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 <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 r � Y <br /> E] DISPOSAL ❑ OTHER Other Information <br /> 4 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: oce,'If eit -Vill, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout I spection prior to grouting and a final inspection. r p <br /> Signed X ' f Title: Q��t-^ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phas 11 rout Inspection Phase I1�Final Inspection <br /> Inspection By f Date ' Inspection By— � Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> db BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> Q <br /> FEE 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issua ce Datt Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />