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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION i <br /> r (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT F *P; * <br /> QUALITY X <br /> (COMPLETE IN TRIPLICATE) WATER Qa <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit toconstruct and/or install the work herein describe This ap lication as <br /> made in compliance with San Joaquin County OrdinagAe No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ll-s- / icit,y/Town <br /> Owner's Name Phone G� 2 <br /> Address City G <br /> Contractor's Name I License# Business Phone ' <br /> Contractors Address Emergency Phone <br /> Is Certificate Of,Workman's Compensation Insurance on File With SJLHD? Yes No oa <br /> TYPE OF WORK,(CHECK): NEW WELL1D DEEPEN ❑ RECONDITION❑ DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION:❑ PUMP REPAIR 13 <br /> -...REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 5 A11v Pit Privy <br /> Sewage Disposal Field — Cesspool/Seepage Pit �' Other <br /> Property Line f Private Domestic Well { Public Domestic Well <br /> F INTENDED USE TYPE OF WELL 112—le <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> R ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing " } � <br /> IRRIGATION w ❑ GRAVEL PACK Depth of Grout Seal <br /> 1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: 'i p op 10 If`!s-ra'J fA� <br /> PUMP INSTALLATION: Contractor t c» <br /> Type of Pump - H.P. x <br /> PUMP REPLACEMENT: ❑ State Work Done k <br /> PUMP REPAIR: ❑ State Work•D e <br /> DESTRUCTION OF WELL: Well Diame� Approximate Depth <br /> Describ ' aterial and Procedure <br /> I hereby certify that I have prep ed this application and that the work will be done in accordance with San Joaquin Coun <br /> ordinances, state laws, and rul and regulations of the San Joaquin Local Health District. I <br /> Homeowner or licensed age 's signature certifies the following:A certify that in the performance of the work for which this perm t <br /> is issued, I shall not empi any person in such the <br /> as to become subject to workman's compensaliori laws of California ' <br /> t <br /> Contractor's hiring or s -contracting signature certifies the following:"I certify that in the performance of the work for which th <br /> permit is issued, i sh I employ persons subject to workman's compensation laws of California."-1-will call for a-6ro nspectio" Ir or to grousing and a final inspection. r' <br /> Signed X Title:'- Date: ' <br /> ,�- (Draw Plot Plan on.Reverse Side) . . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted ! Date <br /> Additional Comments: <br /> Phase It Grout Inspe n` �`" ' ' Phase III Final Inspects <br /> v <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received B July 31 <br /> BILLING REMITTANCE .,r'$ RE T <br /> BASE <br /> imEXPLANATION DATE DATE REMITTED 'AMOUNT DUES CWEC En <br /> AMOL INT <br /> FEE <br /> LESS <br /> PRORATION <br /> ° PLUS <br /> PENALTY <br /> � lE <br /> OTHER <br /> OTHER_-+ <br /> Received by \h to ; Receipt No Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENYIR OMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE:;P.O.Boz 2009 STOCKTON,CA 95201 <br />