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Ail Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR O►rFICE USE: APPLICATION ` <br /> (For Nan-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) -WATER 5 t - �4 D �!� QUALITY ��f _ ,_ 300—00 <br /> Application is hereby madeto the San Joaquin Local Health District fora.permitto construct and/or install thework herein described.This application is <br /> made in compliancepith San Joaquin County Ordinances No 1862 andAhe rules and regulations of the S a.Joaquin Local Health District. <br /> Exact Site Address 0f .f ' ; r rr / ;� faf City/Town <br /> Owner's Na lne fr i"'r 4 } 6c"'f , .; ;? ro Phone <br /> ra <br /> Address ' Gity { <br /> Contractor's Name £ {`1".- ,License# ` E Businbss Phone_ w e, <br /> Contractor's Address _�.,•'� _C'ir4 t ' �! �' ff`'"' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes (..o,....---H No <br /> TYPE OF WORK (CHECK); NEW WELL0- DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 11 <br /> REPLACEMENT❑ ' c.. <br /> DISTANCE TO NEAREST: Septic Tank/(A rr. Sewer Lines `1 Pit Privy `" _ <br /> Sewage Disposal Field Cesspool/Seepage Pit _ Other Q <br /> Property Line Private Domestic Well Public Domestic Well ) <br /> INTENDED USE - TYPE OF WELL <br /> ❑ INDUSTRIAL ©^ABLE TOOL Dia. of Well Excavation -. t <br /> DOMESTIC/PRIVATE ❑ ° <br /> DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C; <br /> ❑ IRRIGATION El 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 /> i Type of Pump <br /> H,P. �m <br /> PUMP REPLACEMENT: ❑ State Work Done I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <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 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 forwhich 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 /> permit is issued, I shall emplof�persons subject to workman's compensation laws of California." <br /> I wit X all for a Gro�t Insprc,on prior torgrouting and a final inspe6fi <br /> Signed X r ! s{� ' �..,r Title: Datr� � <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENTUSEONLY �.. - <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> P II Grout I� pection� Phase III Final Inspection <br /> Inspection By Date � fI� Inspection By Date <br /> Fee Is Dile: 13 ANNUALLY El PER UN C] PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE'.: DATE REMITTED <br /> AMOUNT <br /> FEE 3 .QC. <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Cate Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O,Box 2009 STOCKTON,CA 95201 <br />