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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-Translerable, Revocable, Suspendable) <br /> - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address .11City/Town m s <br /> Owner's Name Phone 6gr %2 I <br /> Address city c, i <br /> Contractor's Name r icense# y2SS5 y Business Phone <br /> Contractor's Address /p mergency Phone —Z7 9'7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION E] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION PP—PUMP REPAIR❑ <br /> I <br /> REPLACEMENT❑ / j <br /> DISTANCE TO NEAREST: Septic Tank e!90 Sewer Lines da Pit Privy <br /> r -Sewage Disposal <br /> Field— A50— -- Cesspool/Seypage Pit .__ ------.- OtAar <br /> - Property Lined Private Domestic Well 200 .:Public Domestic Well <br /> INTENDED USE TYPE OF WELL._. . <br /> ❑ 5DUSTRIAL ❑ CABLE TOOL. � & Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of CasingT <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> u: <br /> 4 ❑ DISPOSAL ❑ OTHER Other Information ,�� <br />` ❑ GEOPHYSICAL Purfacg,"Jeal Insta ed-By: }^'� <br /> PUMP INSTALLATION: Contractor �r l <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done k- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E _ <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 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 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 all for <br /> �a.,Grout Insp tion prior to grouting and a final inspection. <br /> E Signed X — rT ✓l r r Title: © 1 Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> Application Accepte y Date tI <br /> Additional Comme t <br /> Phase 11 Grout Inspection - r '� Pha a III Final Inspection <br /> 1 Inspection By Date Inspection By Date <br /> Fee Is Due: El ANNUALLY - ❑ PER UNIT ❑ PER SITE El EACH [3 January 1 &Received By January 31 u❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING .REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> i <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> l <br /> OTHER <br /> I <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance Date Maiied Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />