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Applic ions Will Be ProcesseliWn Submitted Properly Completed.Be SureTo SignTheAppncailon. <br /> FOR OFFICE USE:�:'� <br /> APPLICATION <br /> Foil Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ;it A r ENVIRONMENTAL HEALTH PERMIT <br /> . yis �o Za5 l���US <br /> (COMPLETE IN TRIPLICATE)�� WATER QUALITY, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein"described.This application is <br /> made in compliance with Aan Joaquin County Ordinance No.1862 and.the rules and regulations of the San Joaquin Local"Health District. <br /> ."J <br /> Exact Site Address �o�d Z C/&%)A- City/Town"' � <br /> Phone <br /> Owner's Name <br /> Address <br /> Contractor's Name License#a �'Business Phone' <br /> tti y <br /> Contractor's Address �✓ Emergency Phone. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes___4—_ No <br /> i TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ cl` <br /> WELL CHLORINATION 13 WELL ABANDONMENT C1 OTHER 11 PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ �! <br /> ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy , <br /> Sewage Disposal Fieldv__ - Cesspool/Seepage Pit °� Other <br /> =1 :a <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I` ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IMIRRIGATION 11N.t7 � ❑ 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 e i <br /> Type of Pump .r `'�,w� j H.P. Q <br /> PUMP REPLACEMENT: ❑ Stale Work Done <br /> PUMP REPAIR: State Work Done '`'' ` P <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 0 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I <br /> t1 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 /> 1 will call for a Grout Inspection prior to grouting and a•final inspection. <br /> Signed X /�=/ 1 c o G ^^ Title: - Date: <br /> L _ (Draw Plot Plan on Reverse Side) T _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 D — <br /> Application Accepted By Date <br /> t Additional Comments: <br /> Phase 11 Grout Inspection se III Final Inspection <br /> Pha <br /> Inspection By } Date Inspection By U <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH, © January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE J(�„ <br /> LESS <br /> PRORATION ! ' <br /> x PLUS <br /> PENALTY ` .t <br /> OTHER <br /> OTHER <br /> y <br /> Received by Date " Receipt No Permit No.. Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 <br />