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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. A <br /> FOR AWFICE USE: APPLICATION /< <br /> If owe le (For Non-Transferable,Revocable,Suspendable) PUMP&WELL 5 <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 N 18 and the rules and regulations of the San Joaquyi Lo4l yealth District. <br /> Exact Site Address 12© City/Town ` <br /> Owner's Name Ole Phone <br /> Address 2,0 City <br /> Contractor's Name Licerrse# Business Phone <br /> Contractor's Address a02S4 AR ft Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi LSJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS <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 lagalled By: ' <br /> PUMP INSTALLATION: Contractor .�00 <br /> Type of Pump H.P. CJS/ <br /> PUMP REPLACEMENT: ❑ State Work Done 0 Or <br /> PUMP REPAIR: State Work Donees <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 jv <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. 44 <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection o rou&ngsonal inspection. <br /> Signed Date: <br /> (Draw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I '� I � <br /> Application Accepted By -a-1-- Date <br /> AdditionalComments: <br /> Phase 11 Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By�f. 6�..-,---Date <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 /> BASE EXPLANATION DATE DATE REMIT D AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />