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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) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordi , nce 1 62 and the rules and regulations of the Sa iaqul��jj Local Health District. <br /> Exact Site Address City/Town 4 ">"; �}"'caL1 _CLd <br /> Owner's Narve s1 /► ,O N_ /�A ��!�" Phone <br /> Address e _ City <br /> Contractor's Name License#1_716 �--�Business Phone____ ,___�^�__ i <br /> �� � �^ � <br /> Contractor's Address mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ _ Q <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION C3 C� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank ! �'f Sewer Lines )G1 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 f) <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing �- <br /> a <br /> 11IRRIGATION 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: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 J <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 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 prior to grouting and a final inspection. <br /> Title: 1 'T %� Date:" '_10- <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> ((( FOR DEPARTMENT USE ONLY <br /> PHASE 1 n �7. 1_ <br /> Application Accepted By JL <br /> - Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection a III Fi Inspection <br /> Inspection By Date— Inspection Date t- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By anuary 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE -9425 <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.Box 2009. STOCKTON,CA S�O'I <br />