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-- t TObign <br /> Applicatia4s.Will Be Processed When Submitted Properly Completed. BSure <br /> F6R'OPME USE: APPLICATION <br /> 4 oll (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application lication is <br /> made in compliance with San Joaquin County Ordinance No. 182 and the rules and regulations of the San Joaquin Local Health District. <br /> �� ? , City/Town <br /> Exact Site Address t <br /> �I Phane11 it <br /> Owner's Name I <br /> City <br /> Address4 1. a. -tom <br /> Contractor's Name <br /> Li erase# J � 7� usiness Phone - r <br /> Contractor's Address7c;L a)- Emergency Phone <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File Wit JLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION ElWELL ABANDONMENT 11OTHER 11PUMP INSTALLATION Pd PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> r Sewage Disposal Field Cessp6ol/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well ; <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODICPROTECTION 13 ROTARY Type of Grout <br /> 13 DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 0 <br /> H.P. <br /> Type of Pumper <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: <br /> # State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 /> Home owner 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 forwhich this <br /> permlt Is issued, I "'6all employ persons subject to workman's compensation laws of California." <br /> I vfill call for a Grout Inspectio do 0 g ing and a final inspection. ! yt <br /> Signed <br /> fd'f itie: Date: <br /> CJ <br /> (Draw Plot Man on Reverse Side) <br /> FO DEP RTMENT SE ONLY <br /> i <br /> PHASE I Date d <br /> Application Accepted By - <br /> Additional Comments: <br /> Phase 111 Final Inspection <br /> Phase 11 Grout Inspection <br /> Inspection 8y <br /> Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER S1TE ❑ EACH ❑ January 1 A Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> I' BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE _ 'EXPLANATION DATE DATE REMITTED AMOUNT <br /> A. <br /> FEE <br /> LESS <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> 3 OTHER <br /> OTHER <br /> t Received by <br /> Date Receipt No, Permit No. is nc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HAZELTON AVE„P.O.Box 2009 STOCKTON,CA 95201 <br />