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Applications Will Be Processed When Submitted Properly Com let �Ve i e Application_. <br /> F.O FIC <br /> FE USE: APPLICATIQ�A, - <br /> 1 !_ <br /> (For Non-Transferable, Rejl,1. Mendable)ENVIRONMENTALTHP WilPUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUA -J �tvlCrr�� <br /> Appl ication is hereby made to the San Joaquin Local Health District fora permit to construct andJo-r3stl t�d�k'herein described.This application is <br /> made in compliance with San Joaquip,Coun Ordinance . IS and the rules and tr11s� int t 15an <br /> ' Exact Site Addr s 40 4 quin cal Health District. <br /> 19 " _ E ity/Town <br /> Owner's Name /T'tv/� � -; Phone �4 � r7 G <br /> � _ ! 7 <br /> Address e city_. <br /> t <br /> Contractor's Name License#� Busin ss Phone � � R <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❑ DEEPEN ❑ RECONDITION© DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WE -� <br /> LL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑-' <br /> R REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> - <br /> INTENDED <br /> Do <br /> Property Line Privatmestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL - -11 CABLE TOOL Dia. of Well Excavation -=- <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> i ❑ 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 /> ❑-GEOPHYSICAL urface Seal Installed By: <br /> ~PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP.REPAIR: � 2-state Work Done �- <br /> .-DESTRUCTION,OF WELL:" --Well Diameter-, -- - Approximate Depth <br />�. •bescribe Material and Procedure <br /> ! hereby certify that I have preps-red-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 thework for which this permit 5 <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 /> I, permit is issued, I shall employ <br /> t persons subject to workman's compensation laws of California," <br /> E I I c for a Gr Inspection prior to grouting and a final ins pe tion. <br /> Signed X <br /> .t 1 <br /> { tle: Date: <br /> f _ _ _,,,,,,_„.„� (Draw Plot Plan on Revers ide) <br /> ¢. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By ly Date <br /> Additional Comments: <br /> Phase Il Grout inspection` Kase III Final Ins ection <br /> Inspection By Date Inspection By % ate /C_ 9- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE yCv� AMOUNT <br /> LESS 11r <br /> PRORATION <br /> PLUS <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> Received by Date 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 />