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Application Will Be Processed When Submitted Properly Completed.Be Sure.To Sign The Application. <br /> FOR OFFICErIliSE: APPLICATION <br /> /p 4,otAJ\ (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYC&n �i xn <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto nsta <br /> construct and/or ill 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 JoaquLocal Healt District. <br /> Exact Site Address 4 ' 1 City/Town _ ,�w►rani tvt�}"��,� <br /> Phone f <br /> Owner's Name �1'�4 <br /> City,' <br /> Address -7 4,Contractor's Name �'� &� License#��Business Phone <br /> Contractor's Address � <br /> �,� it✓" Emergency Phone ' <br /> Is Certificate of Workman'sCompensation Insurance on File ith SJLHD? Yes._ _— No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ _ RECONDITION❑ DESTRUCTION❑T <br /> WELL CHLORINATION 11WELL ABANDONMENT 13OTHER 11PUMP INSTALLATION C3 PUMP REPAIR <br /> REPLACEMENT❑ A l <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other h <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation " 1 <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 ,{ <br /> ❑ DISPOSAL 11 OTHER <br /> Other Information <br /> ❑ GEOPHYSICAL <br /> AL <br /> Surface Seal Installed B <br /> C -- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �r�r H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> r PUMP REPAIR: ' <br /> ® State Work Done <br /> k DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> F <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 /> F <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 or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> 1 I ill call for a Grout Inspe do prior o grou g and a inal inspection. <br /> 4 - le: _ Date <br /> Signed <br /> 4 <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLYN <br /> PHASE I f+ Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection -Phase ItL Final <br /> lIInspection <br /> Inspection By Date Inspection By f� � Date lf` <br /> - { By <br /> Fee Is Due: ❑ ANNUALLY_' ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July &Receiv REMITuIy 31 <br /> BASE ' EXPLANATION BILLING REMITTANCE $ AMOUNT 6UE CHECKED <br /> DATE DATE •REMITTED AMOUNT <br /> FEE FGA <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> s Y� <br /> OTHER <br /> Received by Date Receipt No., Permit No. �, Issuance Date Mailed Delivered <br /> STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 16111 E.HAZELTON AVE.,P.O.BOM 2009 <br />