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APPlicauon <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignThe <br /> APPLICATION <br /> OFFICE USE: <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> v'- <br /> _K* ENVIRONMENTAL HF 'PERMIT L <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetothe San Joaquin Local Health Districttora permitto construct and/or install the work herein described.This application Is <br /> made in compliance with San Joaquin Co%y.Ordin c No_ 1862 and,the rules and regulations of the San Jgapuin`Local Health Distract.. <br /> City/Town ��. . - <br /> Exact Site Address <br /> 11 e17 Phone' �� j <br /> Owner's Name J+1 City cad <br /> i <br /> Address dBusiness Phone <br /> License ' I <br /> # <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes_ <br /> TYPEOF WORK {CHECK}: NEW WELL DEEPEN❑❑ OTHER RECOND❑ ITIOPU❑MP iNSTALLAT TION <br /> 13 PUMP REPAIR❑ N <br /> WELL CHLORINATION ❑ WELL ABANDONMENT j <br /> REPLACEMENT❑ <br /> DISTANCE`TO NEAREST:--Septic Tank,-/a& Sewer Lines C rl,_E— Pit Privy <br /> Other <br /> Cess ool/Seepage Pit Sewage Disposal Field��� r F p <br /> Property Line/[�f Private Domestic Well <br /> C)r Public Domestic Well - <br /> INTENDED USE TYPE OF WELL r 4 <br /> 0-INDUSTRIAL 13 CABLE TOOL Dia.`of Well Excavatiori' 1 <br /> { <br /> DOMESTIC/PRIVATE 13 DRILLED of Well Casing DRILLED f <br /> 13 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC Depth of Grout Seal <br /> GRAVEL PACK i <br /> 11 IRRIGATION Yc - <br /> I��ff ROT,TY Type of Grout Y f+ <br /> 11CATHODIC PROTECTION � � �'l• . a <br /> OTHER Other Information ' <br /> ❑ <br /> 11 DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type*6f Pump <br /> PUMP REPLACEMENT: ❑ State Work Done ) <br /> ❑ State or <br /> Wk Done <br /> PUMP REPAIR: Approximate Depth <br /> .'; w <br /> k DESTRUCTION OF WELL: <br /> Well Diameter � <br /> Describe Material and Procedure <br /> i <br /> Ilcation and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this app' <br /> ordinances, state laws, and rules and regulations of the San Joaquin IL, .' Health District. <br /> Home owner or licensed agent's signature certifies such mannerowing:"I certify that in the as to beco subjec!to:workm nas compensatiorL of the work folaws of Califorwhich this rnia." <br /> is issued, I shalnce <br /> l not employ any person In - <br /> Contractor'shiring or sub signature certifies the following:"I certify that in the performance o!the work forwhich this <br /> permit is issued, I shall employ per ns subje o workman's compensation laws of <br /> ,California." <br /> I will call fora r3rout Inspe ion r to r mg and a final inspection. <br /> Title: ( Date: <br /> I Signed X ' (Draw Plot Plan on Reverse S e) <br /> FOR DEPARTMENT USE ONLY <br /> . s <br /> PHASE I Date <br /> 1 Application Ac pled y <br /> Additional C mmentas II al Inspection <br /> P e I ut inspection Date <br /> Date <br /> d' <br /> Inspecti <br /> Date Inspection By <br /> Fee Is Due ANNU LY ❑ PER UNIT C1 PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t'&Received July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 1 FEE o Q <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> V <br /> ermit No. — - - IssuancDelivered <br /> Received by - Date Receipt No. <br /> L HEALTH PERTdiTISERYkCES <br /> 1601 E.HAXELTON AVE.,P.O.Box 2009 STDCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTA <br />