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Appilcations Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transierable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER;QUALITY i <br /> (COMPLETE IN TRIPLICATE) t . . �k::'nikoty 10 of i ll"fin <br /> Application is hereby made fo the San Joaquin Local Health District fora permit to construct and,/.or,install the work.herein described.This application is <br /> made in compliance with San JoaWn.County Ordinance No.,1862 and the rules and regulations of the San Joaquin.Local HealthYDistrict. <br /> } <br /> Exact Site Address /;� City/Town <br /> j� Owner's Name r° I r• ° r L^ ? ' la e k <br /> ,r City <br /> Address 1 :,'7«;ate ' 'r.: t <br /> Contractor's Name �I• ..y: ' ' tr? *""license#-¢ °`h ��'� Business Phone <br /> Contractor's Address 'r do tG Emergency Phone r' ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL❑' DEEPEN ❑' w RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT,2-- OTHER 13PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> PREPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines .Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property tine Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL I ' ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC I ❑ DRIVEN r Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: I Contractor <br /> Type of Pump H.P. I <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter t Approximate Depth <br /> Describe Material and Procedure <br /> � I �f <br /> I hereby certify that b have prepared this application and that the work will be done in accordance with San Joaquin County <br /> c <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:1 certify that in the performance of the work forwhich this permit <br /> I is issued, I shall riot employ any person.in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring ora�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 /> 1 will�11 �Gou,�,,,Inmspect�ionprior to grouting and a final inspection. <br /> Signed Title: >;-7— Date- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI 1 <br /> Application Accepted By yi -�� Date <br /> - l7'�rz <br /> Additional Comments: Ilk' <br /> Phase II Grout Inspection Phas III Final Inspection <br /> Inspection By �p Date Inspection By Date /�. <br /> Fee Is Due: ❑ ANNUALLY'Iry ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January3 J- � ❑ July 1 &Received By July 31 <br /> �! <br /> REMIT <br /> .BILLING - REMITTANCE $ - - <br /> BASE ' EXPLANATION AMOUNT DUE CHECKED <br /> i� DATE DATE 4.REMITTED AMOUNT <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS ` <br /> PENALTYI�!' y <br /> OTHER <br /> OTHER I r <br /> Received 6y- - - Date - Receipt No. -r Permit NoIss ance_ ate - _- Mailed -Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> .11: a . <br />