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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: / �j APPLICATION <br /> g Cont lal (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> i ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work,herein described.This application is <br /> ,, <br /> made in compliance with San�Joaquin ounty Ordnance . 1862 and theIt"ules and.regulations of the San Joaquin Local Health District. <br /> Exact Site Address Z p i0 /� ?�1►� ity/Town <br /> r- �r• ' <br /> Owner's Name Phone <br /> Address B�L�/ 7`Q��^Ip4 G!-= -i 'd e - City <br /> Coritactor's Nam lC 1 License"# —7 AC Business Phone' .� <br /> Contractor's Address 4d Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on FilTWth JLHD? Yes NoTYPE OF WORK (CHECK): NEW WELL❑ I DEEPENRECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR% 1 } <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 /> ❑ 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 O <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> r V C- <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. q <br /> Home owner or licensed agent's signature certifies the following:')certify that in the performance of the work for which this permit O1` <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 suticontracting'signatCre 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 /> call for a Grout Inspectloh rI&It grou d a al Inspection. - <br /> Signed r e: .. _ Date: <br /> r } (Draw Plot n on Reverse Side) <br /> �r-r- <br /> i <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I "..q , <br /> • Application Accepted By <br /> ' if D Ll Date <br /> Additional Comments: <br /> Phase II Grout Inspection hase III Final IJ ection <br /> Inspection By Date Inspection B - Date �� t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ;BASE - EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE cab S �t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 4 <br /> r <br /> OTHER <br /> 4 Received by Date Receipt No. Permit No. Iss ante Dafte.. Mailed Delivered .. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />