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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> a (For Non-Transferable,Revocable,`Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health DistrictVfo,r a permit to construct and/or install the work,herein described.This application is <br /> made incompliance with San Joaquin C my Ordinance 862Ag= <br /> ions of the Sa oaquin Local feaith District. <br /> Exact Site Address l" City/Town <br /> Owner's Name I 9172 x '' Phon <br /> Address r City <br /> Contractor's Name icense# ._.� Bus Hess Phone' <br /> Contractor's Address a ' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No q y <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ PRECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑' r� OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ _ _ _ <br /> DISTANCE TO NEAREST: Septic Tank ysewerl-ines-1 Pit Privy (n <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well •34�� 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 WON <br /> ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Informi n <br /> 11 GEOPHYSICAL Y-•..... Surface Se Installed By: <br /> PUMP INSTALLATION: Contractor?. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: —0-State Work Done ol <br /> PUMP REPAIR: ❑ State Work Done (1� <br /> DESTRUCTION OF WELL:- + Well Diameter -� Approximate Depth { 1 V 1 <br /> Describe Material and Procedure I <br /> : .�sR <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County CA <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. • <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 orsub-conlracting signature certifies the following:"I certify that in the performance Of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws oaf California 5 ;L—/6,P <br /> te/`�"' <br /> I will call f a n c�iiin p r to grouling and a final inspection. P _ <br /> Signed X Title: o Date: . <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f _9 � <br /> Application Accepted By Date <br /> Additional Comments: rzv�� <br /> Phase 11 Grout inspectionh 1 Final spection <br /> .Inspection By M �n Date Inspection By tofDate Q - <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ' ❑ PER SITE ❑ EACH " 0 January 1 S Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> s DATE DATE REMITTED AMOUNT' <br /> FEE <br /> LESS- _.�-...rt... .s-��. ....:.._ _ - »- .W... w.w..�..... _ <br /> PRORATION r ' <br /> PLUS <br /> PENALTY- <br /> OTHER " <br /> S i <br /> OTHER t . <br /> Received by - Date "Receipt No. -Permit No." I suan a Date + Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />