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R Applic ons"Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> �Coi,,Crxo 4,R (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> and/or install the work-herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District fora permitfoconstructan <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 .54411P A4A- ct" 10-7 �0 rX City/Town <br /> (� L•r ar yep 6Pj},�"' Phone s <br /> Owner's Name r^^4 <br /> Address `S _��City _rna► 0M�� <br /> Contractor's Name License# �f37y� Business Phone �• ! <br /> &)� Emergency Phone I <br /> Contractor's Addres _ <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes e No ) j <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 11 DESTRUCTION© � t <br /> ❑ PUMP❑ PUMP INSTALLATION U <br /> ❑ OTHER J <br /> WELL CHLORINATION ❑ WELL ABANDONMENT .L ) <br /> E REPLACEMENT❑ ,, i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field _Cesspool/Seepage t Pit Other i <br /> Property Line Private Domestic Well Public Domestic Well i <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> k' ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ` <br /> Iff IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC,PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Install y: <br /> PUMP INSTALLATION: x . Contractor �__� <br /> ,. Type of Pump �c� _A H.P. ] <br /> 1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: '. _. ® State Work Done - f <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 /> # <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 II �for Grout Inspection prior t gr in and inal inspection. <br /> Signed itle: -��•g Date: <br /> i (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I U <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pha I nal Inspection <br /> pate Inspection By Date <br /> Inspection By Icy <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT �-p�PER SITE - .❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By Jul <br /> REMI <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> D TE DATE REMITTED AMOUNT <br /> PEE <br /> LESS <br /> y PRORATION <br /> } PLUS <br /> PENALTY <br /> ( <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH.PERMIT/SERVICES "101 E.HAZELTON�AVE.,P.O-Box 2009. STOCKTON,CA 95201 <br />