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li t %I ocesse U16 In Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> SAN 1 1(�B2(For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> jffi�,WONMENTAL HEALTH PERMIT <br /> ~ Qr"+Qv1N tCT WATER QUALITY <br /> (COMPLETE IN TRIPLICAT {�I blSTR <br /> Application is hereby made to t1��110uln Local Health District for a permit to construct and/ <br /> install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance N 1862 and lbe les and regulations of the San Joaquin Local Health District. <br /> PExact Site Address 1 fy n ()n 'e 5 City/Town <br /> Owner'sNarne f"/' Phone <br /> Address 17 y City <br /> Contractor's Name License#&"_060Bu i ess Phone w <br /> Contractor's Address Emergency Pho z'�"(� � 11 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION 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 /> ❑ yNDUSTRIAL ❑ 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 ` ll 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 /> fi <br /> �1 <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 sub'ect to workman's compensation laws of California." <br /> will call r a Grout Inspect' rior to outing d a final inspection. <br /> Signed X Title: Date: <br /> (Draw lot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Yui-��� ►� Date '— <br /> Additional Comments: <br /> PhagNITrout Inspection Phase III Final Inspection <br /> Inspection By �f 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED t�hry AMOUNT <br /> FEE Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 14 <br /> Received by Date Receipt No. Permit No. ssuance 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 />