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==a' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> WR OFI:IC U E: APPLICATION <br /> Z, (For Non-Transferable, Revocable,Suspehdable) 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)9 , Local Health District. <br /> Exact Site Address City/Town voc�� <br /> Owner's Name ` Phone <br /> Address '7 City <br /> Contractor's Name License#/!;! 73 Business Phone <br /> Contractor's Address Emergency Phone 4e41C^9(I. a_j� r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes k_1 No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR LAY <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �1 <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 /> XDOMESTIC/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 /> ❑ GEOP-HYStCAL- <br /> ,Sur ace,Seal InstaNedBy: --- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump lsw H.P. f <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 <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:")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 shalt employ persons subject to workman's compensation laws of California." <br /> 1 w all r a Grout I ection prior to grouting and a final inspection. <br /> Signed X Title:< `/c - Date:i(M , <br /> (Qraw PIanon ReverB Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date`L�_02111 '81`( <br /> Additional Comments: lam' <br /> Phase 11 Grout Inspection has ill Finallnsp!ctfon <br /> 1RSp®ct►on$y- Date Inspection By Ly 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 AMOUNTDOE CHECKED <br /> FEE 5 J � <br /> LESS <br /> `PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER s <br /> OTHER <br /> Received by Date Receipt No. Permit No. IssuaAce 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 />