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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FORyOFFiCR USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaqui Loc Health District. <br /> Exact Site Address �'� t7 lIV !•1 I (.f h Q+ City/Town O=C, 'a�✓s�. <br /> Owner's Name Phone <br /> Address City C-1 <br /> Contractor's Name License#,�3-7s-_CBusiness Phone Vel —7(s 74 C <br /> 1 <br /> Contractor's Address CQ6.2 k Ja Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes No <br /> LJ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN RECONDITION DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Ir" PUMP 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 /> ❑ 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: .2 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> r— <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> Home owner 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." ' <br /> I ill call for a Grout In ct n or grouting a final inspection. <br /> Signed�� itle: 74na P Date: <br /> (Draw PI Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date `_ <br /> Additional Comments: <br /> sell Grout Inspection Ph spection <br /> Inspection By Date Inspection By Date <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE t'b (la <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ) a� ID ;;:LS )I <br /> Received by Date Receipt No. Permit No. 115suance to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />