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flppttuauune nnl,®er1uve®e®14 "imp vusnnra.ev .,era„l <br /> n <br /> FOR OFFICE USE; APPLICATION �rTJ ru�j ��-:allt ' <br /> (For Non-Transferable' Revocable Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT - <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe 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 Sa oaqui�nocal e I ISistrict. <br /> Exact Site Address to.• City/Town 4 N.{ <br /> Owner's Name <br /> ! t UJ L 1� Phone N IN C c - 5's-- <br /> Address { , �' City—E <br /> Contractor's Name11K ? '� �� License tf Vii.__{'�' Busin sS Phone___ <br /> Contractor's Address fi` _ Lo • Emergency Phone - —==J -------- <br /> Is Certificate of Workman's Compensation I,nsuron File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLL� DEEPEN ❑ RECONDITION❑ DESTRUCTION© ` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST; Septic Tank _ "�) Sewer Lines _._.._ Pit Priv <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well «'T Public Domestic Well <br /> INTENDED USE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL pia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ( . I <br /> ❑ plemESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout WIft - <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 1 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:"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:'9 certify that in the performance Of the work for which this <br /> pe tt is issued,`I all emplo ,persons subject to workman's compensation laws of California." _ <br /> I w all for a Gr i t nsp 11 n priort ;grouting and a final Inspection. <br /> Signed X _ Title: is i 1:' �.� D. <br /> (Draw Plot Plan on Reverse Side) <br /> 0FOR DEPARTMENT USE ONLY <br /> PHASE I li � ��� (08 Date <br /> Application Accepted By v <br /> Additional Comments: <br /> Ms. II Grout Inspection Phase Ip Final inspection <br /> Inspection By Date Inspection By _ Date —F <br /> Fee <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 S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER n <br /> I � <br /> 1SC7 <br /> I Received by I bate k Receipt No. Permit No. Issuance 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 />