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Applications Will Be Processed When Submitted Properly-Completed. BeSureTo SignTheApplication. <br /> FOFt OFFICE USE: - APPLICATION * <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> K - <br /> A111ENVIRONMENTAL HEALTH PERMIT <br /> y(CO ETE 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 <br /> made in compliance with San Joaquin C unty 9idinance No. 18UarLd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �i�� teOK A4f P7 City/Townd <br /> r <br /> Owner's Name Phone DA l <br /> ! Address — iE r City <br /> Contractor's Name — (!!?:f , License#�?9_,!jAl Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesXNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION C1 WELL ABANDONMENT ❑ OTHER 13PUMP INSTALLATION.k PUMP REPAIR❑ <br /> REPLACEMENT❑ �I 1 <br /> i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pitt her 113 <br /> f Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL M <br /> ❑ INDUSTRIAL i ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE I ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I@ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTIONAl <br /> 1:1ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - S rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> f Type of Pump r • H.P. ell <br /> PUMP REPLACEMENT: ❑ State Work Done N <br /> PUMP REPAIR: I' ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia! and Procedure Q <br /> I-hereby certify that I`have prepared this application and that the work will be done in accordance with San Joaquin County <br /> .,6rdinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I, <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> ' 1 will ca a Gro '�Insp f rior to grouting and a final inspe on <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Ide) <br /> L FOR DEPARTME USE ONLY <br /> PHASE <br /> Application Accepted By Date 5 9 <br /> Additional Comments: <br /> f Phase II Grout Inspection hinal Inspection 2 <br /> Inspection By Date Inspection By _ Date ! <br /> ' Fee IS Due: 11 ANNUALLY C1 PER UNIT PER SITE C1EACH ❑ January 1 &Received By January 31 ElJuly 1 &Received y 31 <br /> REMIT <br /> 1 IM BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE DATE REMITTED <br /> i� AMOUNT <br /> I� <br /> FEE r r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER I' <br /> OTHER l�. <br /> ` L1z 11.E <br /> �P __79--\1��, Lo�51�79 <br /> Received by Date - Receipt No. Permit No. Issuance bate Malted Delivered - <br /> r <br /> 1601 E.HAZELTON AYE.;.P.O.Box 2009STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES . , • ""�'"µ'" <br /> 0 <br />