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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) <br /> �— PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY Z3, Or <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermit toconstr orm sapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 a d the rules and regulations of the San J Local Health District. <br /> Exact Site Address City/Town 11 <br /> Owner's Name eA j2Phone' <br /> Address City i' <br /> Contractor's Name t License k3109 4/y Business Phone 7 7!7 <br /> Contractor's Address CQ�I.Gt_ —�� Emergency Phone —,54 rrk" a <br /> Is Certificate of Workman's Compensation Ins ance on File With SJLHD? Yes �� No a , <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION13 [" <br /> WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER ❑ PUMP 1NSTALLATIOIV I- PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank / Sewer Lines Pit Privy <br /> Sewage Disposal Field _ CesspooI/Seepage Pit Other <br /> Property Line QL6 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of WellExcavation <br /> 11 <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> t <br /> [3DOMESTIC/PUBLIC C] CaDRIVEN Gauge of sing Je-4— <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal SD <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r' - <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 - _2- <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 /> permit is issued, I shall employ persons subject to workman's compensation laws of,California." <br /> Iwill all ffovr� Zinspectiona priorJo grouting and a final inspection. <br /> Signed X � '/// U 4 1140 0T!!s` Title: &a,)/fit Date: <br /> (Draw Plot Plan on Reverse Side) <br /> DEPARTME T USE ONLY <br /> PHASE <br /> Application Accepted By '11(1,71,, — Date /If 3 ? / <br /> Additional Comments: T <br /> Ptpse II Grout inspecti n ,l Phase III Final Inspectipn <br /> Inspection sy ate / _ Inspection By� Date �f <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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601-E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />