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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTKPERMIT .ale '(7/4� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ,.m. I i <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> i <br /> made incompliance with San Joaquin C2 ty.Ordinance No. 62 and the rules and regulations of the Sja ioa� quu'In_LocaI Hpolth District. <br /> Exact Site Address 0 NA City/Town ��_,,,,�,.��, <br /> Owner's Name '" " Phone <br /> Address "' City I <br /> Contractor's Name a `� <br /> 5 ';. lam' License#lam . Business Phones /✓ V 7' <br /> Contractor's AddresV2 C fv,- T. ai 04mf ��,. emergency Phone ` A& "Z <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No f..� <br /> TYPE OF WORK (CHECK): NEW WELL @—" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ A' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION &' PUMP REPAIR❑ q <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank oa Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage,Pit Other <br /> -Prpperty Line UO2 Private Domestic Well Public Domestic Well I <br /> INTENDED USE ` 1; TYPE OF WELL J <br /> ❑ INDUSTRIAL 12'°lABLE TOOL + Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Oi <br /> ❑ IRRIGATION ❑ GRAVEL'PACK Depth of Grout Seal _ <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DiSPOSAL 0 OTHER -, Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump "5&L 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.. T <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 /> Homeowner 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 orsub-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 will)callfora Gout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: 04 ' �. <br /> (Draw Plot Plan on Reverse Side) <br /> FO EPARTMENT USE ONLY <br /> PHASE I J� � <br /> Application Accepted By `-� `� Date AoJ l � I <br /> Additional Comments: <br /> Ph se II Grout Inspegion_ Phas III Final Inspection. <br /> Inspection By & mate T J d fr/A�l � _ Inspection By Date Sr <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ ulyJ 1,&,Received By July 31 <br /> REMIT <br /> t BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED . AMOUNT <br /> FEE <br /> } <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 - --� Li_ <br /> Received by 6ate Receipt No Permit No. lssi5ance Dat.cf Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 i <br />