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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: . I Y APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> I Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin Count Ordinancetio. 1862 arAthe.rules and regulations of the San Joaquin Local H lth District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address d City_-Z4.f1l� �.f ,� <br /> Contractor's Name License#t7C Business Phoney <br /> Contractor's Address 0 !l f9 Emergency Phone <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 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 <br /> ❑_, I/N�tJSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> lla"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 /> l ❑ GEOPHYSICAL c Surfac Seal installed By: <br /> I 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 /> i <br /> Describe Material and Procedure <br /> I <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I IIIc I!pr a Grout Inspection prior to grouting and a final inspection. <br /> Signe Title: Dale: <br /> t (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 3" <br /> Application Accepted By Date <br /> 1 Additional Comments: <br /> > ri <br /> r Phase II Grout Inspection Phase III Final inspection <br /> Ifi Inspection By Date Inspection Bylletl--k � ""� Date Z-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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> FEE i <br /> LESS <br /> PRORATION <br /> PLUS r� <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date" 4%_,fwReceipt No Permit No. Issuance Date Mailed D ered I <br /> ��APPLICA'NY=RETURN-AL'L COPIES-T651PERMIT/SERVICES ^� = "' 1601 E.-HAZEdON AVE.,R6 ao- o— STBCKTONVA-97520-1 <br /> T <br />