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I ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> f FO ;OFFICE USE; I APPLICATION -Jf <br /> (For Non-Transferable, Revocable, Suspendable) <br /> Y ENVIRONMENTAL HEALTH PERMIT PUMP&WELL � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY -- <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is a <br /> made in compliance with San J ,i 'n County OrdinancgT. 1662 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address (�Q,, City/Town _z"y( <br /> Owner's Name. <br /> A,,WAZ-L1 94 <br /> Address City <br /> Contractor's Name �M •� �� f _ <br /> License_ Business Phone <br /> Contractor's Address Emergency Phone — <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELL 19 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER 11 PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ II <br /> DISTANCE TO NEAREST: Septic Tank i Sewer Lines 1 Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property LinePrivate Domestic Well Public Domestic Well 5 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> r <br /> �I DOMESTIC/PRIVATE 9 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ZGRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION I 5*ROTARY Type of Grout 1 ' <br /> ❑ DISPOSAL ❑ OTHER Other Information t <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �I <br /> PUMP INSTALLATION: Contractor 03 1 <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 V <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 /> r <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which th is permit. <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." l <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 taws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> r <br /> Signed X Title; Date: <br /> IN (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date[ <br /> Additional Comments: �M <br /> Phase`'ll Grout Inspection Phase III Final Inspection <br /> Inspection By �p bate Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY 'I�❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju€y 1 &Received By July 31 <br /> i REMITTANCE $ REMIT <br /> BASE BILLING REM <br /> �p EXPLANATION AMOUNT DUECHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION Ip _ <br /> PLUS <br /> PENALTY !!I� <br /> OTHER <br /> OTHER <br /> Received by Date IY. Receipt No. Permit No, - I uanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E..HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />