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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 HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY /o?. <br /> s/� �• + <br /> Application ishereby made tothe San Joaquin Local Health Qistrictforap rr oconocons�trd an /orlrl5talltheworkherelnd crib This application is <br /> made in compliance with San4oaq in County rdinanc 1862 and.t uI�F les and re ufations of the San r <br /> g alth District. <br /> Exact Site Address a <br /> itx,(Tiov�rn 1 �' is- rr?-r' <br /> Owne'r's Name Phone <br /> Address r` City <br /> Contractor's Name License# Business Phon `0(99 l <br /> Contractor's Address `+ Emergency Phone <br /> Is Certificate of Workman's Compensation Insur ce an Fife With SJL D? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑•- WELL ABANDONMENT-0 OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit. Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE € TYPE OF WELL ` ~ <br /> L❑, IN�STRIAL ❑ CABLE TOOL Dia of 1Nelf-Excavation <br /> LJ'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /42 <br /> ❑ IRRIGATION �❑`GGRR VEL PACK Depth of Grout Se I <br /> ❑ CATHODIC PROTECTION t�'ROTARY Type of Grout <br /> ❑ <br /> DISPOSAL ❑OTHER Other Information` <br /> ❑ GEOPHYSICAL j , — Surface Seal II tailed y: ___ 1�i�Tf d7l�r • <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 26 H.P. <br /> PUMP REPLACEMENT:r ❑ State Work Done a <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> - Describe Material and Procedure 1 _ <br /> 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 Healthj District. ,�' t <br /> Home owner orlicensedagent'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 I <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." <br /> ?llcal for Grout Inspection priof 10 grout'rig and a final inspection. tr <br /> Signed')( Title: Date: <br /> (Draw Plot Plan on Reverse Side) V <br /> FOR DEPARTMENT USE ONLY <br /> PHASE - <br /> Application Accepted By R Date 9� � <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By .fit Date!VZ7/14_ Inspection By`" ° %.Date n)' <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 , DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> FEE 4+. <br /> 1 <br /> LESS t <br /> PRORATION r <br /> r , <br /> PLUS' <br /> PENALTY <br /> r <br /> OTHER r <br /> OTHER <br /> Received by Date Receipt No.- - r Permit No. - _ ls4uanceDate I Mailed Delivered �. r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />