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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 made to the San Joaquin Local Health District fora permit to construct and/or instal I the work herein described.This application is <br /> made in compliance wit n Joaquin County Ordinanc .1862 and the s an egula'1 s of the San Joaquin Local Health District. <br /> Exact Site Address ' FCity/Towne <br /> ' t f Phone/J 7— 8 9 5-1 D G( 4 <br /> Owner's Name �l'3v^ <br /> Address on City <br /> Contractor's Name License usiness Phone <br /> Contractor's Address Emergency Phone I <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION �� PUMP REPAIR <br /> REPLACEMENT❑ l <br /> DISTANCE TO NEAREST: Septic Tank / t d 'f Sewer Lines���!�" 'r" Pit Privy <br /> Sewage Disposal Field Cesspool/Se <br /> ege 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 /> M'DOMESTIC/PRIVATE M'DRILLED Dia. of Well Casing �� C <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing G c <br /> ❑ IRRIGATION ❑,.,�, GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ILJ'RCOTARY Type of Grout P ''��' <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surf9ce Seal I tall By: �✓ <br /> PUMP INSTALLATION: Contractor f <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 <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 /> I AvWil for a sp on prior to grouting and a final inspectio 9 <br /> Signed X e: Date: <br /> (Draw Plot Plan on ReverseAide) <br /> FOR DEPARTMENT USE ONLY C Xl <br /> PHASE I \C� v <br /> Application Accepted ByaA..., Date <br /> tn- <br /> Additional Comments: <br /> Pham II GroW Inspection p ase III Final Inspection <br /> Ins — w pec/tion By t Date �5 O l Inspection By Date �—/3— P <br /> IZ <br /> �F6e s Dub: ❑ 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE S 4L -S'3 d a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER , <br /> 314 33 1b ! 3 <br /> Received by Date Receipt No. Permit No. Is ance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />