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Applications Will Be Processed When Submitted Properly Completed. Be SureTo Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPL TE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for apermittoconstruct and/or install the work herein described.This application is y. - <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address / d City/Town +�• <br /> Owner's Name •(.�• Z Phone <br /> Add res s7 7 7� l cr - J1 City l� y� �,• <br /> Contractor's Name - l�1✓ { pYl License#�S�S7S� Business Phone <br /> Contractor's Address ©r � y +��� Emergency Phone j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes x No V <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ^� <br /> W 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 /> ❑ GEQPHYSICAL r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ; <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 9 State Work Done 4 ' <br /> PUMP REPAIR: ❑ State Work Done ; <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Y <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. t M <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 for which this - <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. + <br /> Signed X Title' Date: <br /> r - <br /> - Draw Plot Plan on Reverse ide) <br /> a <br /> FOR DEPA MENT USE ONLY <br /> PHASE l j <br /> Application Accepted By Date <br /> Additional Comments: <br /> ' Phase II Grout Inspection Ph !II Final Inspectio"ReceivedBy <br /> Inspection By Date Inspection By ' DatFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACHJanuary 1 8 Received ay January 31 ❑ J BILLING REMITTANCE AMOUNT O E <br /> BASE EXPLANATION DATE DATE REMITTED <br /> , AMOUNT <br /> FEE <br /> SSS <br /> LESS } <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER ! <br /> OTHER <br /> Received by Date Receipt No.. Permit No -__.. I sua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH•PEFIMMSERVICES'6 Q� 1601 E.HA2EL7ON AVE-,P.O.Box 2009 STOCKTON',CA 95201 - <br /> 1 kms,.. • � - � ... - <br />