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Applications Will Be Processed When Submitted Properly Complridd evsbrmvdSign TneAppl)c>��IQn• ) <br /> FOR of FICE use: APPLICATION �''J <br /> (For Non-Transferable, Revocable,S dablMI G 2 91979 PUMP&WELL <br /> L <br /> ENVIRONMENTAL HEALTH PERMIT JQAQ�IN LOCAL <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) SAH1��p TTH ptiSTRLCT <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ ►14et�1e work herein described.This application is <br /> made in compliance vviJtJaZa9 JplaquinCouZ7 Ordinance No. 1852 t e rules and regulations of the San Joaquin Local He�D�rict. <br /> Exact Site Address City/Town ) ) <br /> Owner's Name <br /> �� � �V �� Phone <br /> Address _ City <br /> 1p License - ' _ J� usi�e^s Phon <br /> Contractor's Name ; # B1.�� <br /> w Contractor's Address1l s7Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION 13DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER Ili 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 /> E: <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/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 DISPOSAL ❑ OTHER Other Information _4z_ <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /># PUMP REPLACEMENT: ❑ State Work Done4 110 11101, <br /> - <br /> PUMP REPAIR: Oa/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 /> c <br /> { <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this perm) <br /> f is issued, l 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 ify that in the performance of the work for which this <br /> permit i ued, I shal p y persons subject to workman's compe tion laws of California." <br /> Grout pec on prior to grouting and a final inspe on.--- <br /> Signed <br /> n.- -- <br /> Signed X Title: Date: 17 11; <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTM NT USE ONLY <br /> PHASE <br /> Application Accepted By Date 7� <br /> Additional Comments: <br /> Phase II Grout Inspection Phase Ili Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 S Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLkNG REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 5— <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ` OTHER cc�� <br /> ? <br /> Received by Date Receipt No. Permit No Issuance Oate Mailed Delivered <br /> APPLICANT—RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />