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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE, APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> '............. <br /> � ENVIRONMENTAL HEALTH PERMIT <br /> 6UfflPL ry rRlPucwTef WATER QUALITY <br /> 3 Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> 1 made in compliance t Gomty Ordin c 1862 and t r les and regulations of the San J I ea h District. <br /> Exact Site Address �� City/Town �'y� r� <br /> Owner's Name /^A Phone z/ — ..7 2.( d <br /> Address r�� � '' City - at <br /> Contractor's Name n.�` y`kk License# Business`Phone V t <br /> Contractor's Address 20 2-4- !i_:LA_ iL&WLAEmergency Phone RV <br /> Is Certificate of Workman's Compensation Insur a on File With Si D? Yes No <br /> 1 TYPE OF WORK (CHECK): NEW WELL SK DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> 1 REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ D IC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> RRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ RY Type of Grout Q CK <br /> r O <br /> 11DISPOSAL N-15THER 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 /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> s <br /> Describe Material and Procedure <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.ruies and regulations of the San Joaquin Local Health District. <br /> t 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 or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> t permit is issued, I sh employ persons subject to workman's compensation laws of California." <br /> ill all la, ut s do prior to routing and a final inspection. <br /> Signed X Title: if 1 r C_Q0 Date: <br /> r (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE t <br /> I Application Accepted By J, Date <br /> Additional Comments: <br /> t ha a II Grout Inspection Phase Ill Fina nspection <br /> l Inspection By Date - Inspection By Date <br /> - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $? REMIT <br /> BASF EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> F OTHEH <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issu nce Date\ Mailed Delivered - <br /> k'r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1501 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br />