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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) <br /> - - <br /> QT) PUMP&WELL ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinan a No. 1862 and the rules and regulations of the San Joaquin La al H Ith District. <br /> Exact Site Address r n J City/Town <br /> f Owner's Name Ile Phone <br /> Address �' City <br /> Contractor's Name License#IJE3-721,1 Business Phone_ 6 v 76 7 <br /> Contractor's Address �' h� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes�/ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ® PUMP REPAIR r <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 /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PURL C1 [.)RIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> t ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ 'GEOPHYSICAL Surface Sea__l I tailed By: <br /> PUMP INSTALLATION: Contractor tJ <br /> a Type of Pump A H.P. <br /> ,- �7- w <br /> PUMP _ .� State Work Done_ - / 4 Z � - -+-� ... 0 <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout Inspection riar to routin nd a final inspection. <br /> Signed ` le: a Date: r <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> J <br /> PHASEI <br /> Application Accepted By JftDate.__ <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ar Phase 111 Final Inspection <br /> I� Inspection By Date Inspection By—� Date <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S/ <br /> LESS <br /> PRORATION A v <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t <br /> tt OTHER. <br /> l <br /> Received by Date Receipt No. Permit No. lAsuancle Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 j <br />