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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> -, 6Q �, (For Non-Transferable, Revocable, Suspendable) PUMP.&WELD <br /> ENVIRONMENTAL HEALTH"PERMIT <br /> (COMPLETE IN TRIPLICATE)-$-%_-5"fj.,S. wo c_ gJR TER QUALITY � I q 3 _ �L rQ 7 <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 /> made in compliance with San Joaquin County Ordinance No. 1862 and the egu <br /> "rule and rlations of the San Joaquin Local Health District. <br /> Exact Site Address'3 a 0 ice " .f il � ' " City/Town <br /> Owner's Name *,: Phone <br /> Address f ity <br /> OF <br /> Contractor's Name r ',License:#/9,_2_ Business Phone-, <br /> Contractor's Address " AJ A" :Emergency Phone <br /> Is Certificate of Workman's Compensation%Insurance on File With,SJ LH D? Yes_ �t No <br /> TYPE OF WORK (CHECK): -NEW WELL❑ DEEPEN ❑ RECONDITION❑ OESTRUCTIONO — T ' - 7. =1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ _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 n I <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 /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _._. <br /> PUMP INSTALLATION: Contractor I"rte <br /> ..: Type of Pump H P / <br /> ( � <br /> PUMP REPLACtMEENT: ❑ State Work Done 1+ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i <br /> Describe Material and Procedure <br /> x • <br /> I hereby certify that l 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 /> Homeowner or licensed agent's signature certifies the following:A 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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 <br /> j <br /> I ill call for a Grout Inspectigrl p ' r o gr inkari final inspection. ¢ <br /> Signed itle: Date: �� y �•� <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 0 1 ] <br /> li / a <br /> Application Accepted By Date - <br /> Additional Comments: I <br /> Phase 11 Grout Inspection P III Fina nspection oe <br /> Inspection By Date Inspection By Date � 2 <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 /> - "EXPLANATION BILLING REMITTAN_CE $ AMOUNT DUE CHECKED <br /> -BASE DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS x- <br /> PRORATION <br /> }GG <br /> PLUS d <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date" Receipt No. Permit No..- ;,Is uance Date Mailed- "Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />