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€' Applications Will Be Processed When Submitted Properly Completed: re 'Wgf�hE-AppI l <br /> lications 1 <br /> FOR,OFFICE USE: APPLICATION . <br /> (For Non-Transferable, Revocable, Suspend MAY 1980 <br /> PUMP&WELL HEALTH PERMIT 1n(�; ll . <br /> WATER QUALITY SAS PUMP CT ; <br /> (COMPLETE IN TRIPLICATE) 11�� � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install�tFle&T�ereiDn described.This application is <br /> made in compliance with.Sar�Joaquin i OrdinanceNo. 1862d the rules andltions of the Saui�A.8)-7He�1SttiJ;1i tric� <br /> Exact Site Address �[ �} > City/Town G-�> <br /> Owner's Name U ;2/ 4 Phone <br /> f Address � Cit <br /> r�-7y <br /> Contractor's Name Z'4 License# � � Business Pho <br /> 4 <br /> Contractor's Address 1. Emergency Phone Llfes <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK {CHECK): NEW WELL❑ .._,DEEPEN ❑ RECONDITION❑ DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> I 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 01 <br /> PUMP REPAIR: State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth S <br /> Describe Material and Procedure <br /> S <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. .� <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 /> j Contractor's hiri r sub-contracti i nature certifies the following:"I certify that in the performance of the work for which this <br /> permit ' ssu shah employ ersons ubject to workman's compensation laws of California." <br /> I wi cal r spection 'or to routing and a final i�pverl <br /> ect <br /> r <br /> I Signed X v x Title: Da1e(Draw Plot Pian onese Side) <br /> I <br /> FO DEPAR MENT USE ONLY <br /> PHASE I <br /> Application Accepted By Dat ` CPO <br /> Additional Comments: - <br /> Phase II Grout Inspection ase ill final Inspection _�� <br /> Inspection By Date Inspection By Date <br /> od— <br /> Fee Is Due: ❑ ANNUALLY _ ❑ PER UNIT PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I <br /> _ REMIT <br /> BASE EXPLANATI N BILLING REMITTANCE $DATE DATE - REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by .. Date "Q` .. Receipt No eri No. Is uance Dikte Mailed Delivered <br /> APPLICANT—RETURN ALL C~ S TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />