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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, j i <br /> FOR OFFICE USE: APPLICATION '# <br /> (For Non-Transferable, Revocable, Suspendable) .,t - s1]I, <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> (COMPLETE IN TRIPLICATE)t oZq/g c ALJ iz7r_C t o7�-AeJWATER QUALITY D 0'7---L'*O — <br /> r; <br /> Application is hereby made to the San Joaquin Local Health Dlstnctfor a permit to construct and/or install the work herein described.This applicatiovi n s <br /> made in compliance with an Joaquin County Ordinance No. 1862 and a rules and reg�ations of the San Joaquin Local Health District.' <br /> Exact Site Address ity/Town <br /> per" ALL/p7T r <br /> Owner's Name one <br /> Address City pu <br /> I <br /> Contractor's Name License# �¢QJ Business Phone <br /> Contractor's Address - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL Ia-'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ _ fiewer Lines Pit Privy, t <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE ,�, TYPE OF WELL N <br /> ❑, IND STRIAL &-CABLE TOOL Dia. of Well Excavation 0 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing 3 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> EL-riIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout t W <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Syefape Seal Installed B ; <br /> PUMP INSTALLATION: Contractor <br /> /C <br /> Type of Pump IVH. . 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 /> Homeowner or licensed agent's signature certifies the following:"!certify that in the performanceof 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 hiringor sub-contracting signature certifies the following: K <br /> g g g:"I certify that in the performance of the work torwhich/his � <br /> permit is issued, I shall employ persons subject to workman's compensation_laws of California."- <br /> I WiIIEWorja Grout Inspect' rior to grouting and a final ins_pecygn— p� <br /> Signed X � Title: 1114,m Date: <br /> ( aw Plot Plan on Reverse Side) <br /> . 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Dat i <br /> Additional Comments: <br /> ase 11 t/InspeclioIn / D h se III Final)Inspection a f <br /> Inspection By 7 l �7 C t/ inspection By Date 0 � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE 3. DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - -Date Receipt No. Permit No. Ishuancle Date Mailed Delivered i <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 J <br />