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Applications Will Be Processed When Submitted Properly Completed. BeSureTosign <br /> ! <br /> FOR oFF� E u E: APP IdATION 1 <br /> --- (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> BIER Q 4LITY !J ��1 —�";:: <br /> (COMPLETE IN TRIPLICATE)ff�'75..IIJ "� G`t ` <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the herein described.This riot.application is F <br /> made in compliance with n Joa uin Count 0rdinan No. 1 2 and th�_ules and r gulations of the Sal oc a l istrict. <br /> �y yG(J�� ( �+_N> City/Town <br /> Exact Site Address - ' <br /> Phone <br /> Owner's Name G f City <br /> Address Bu ess o <br /> ContractorName 1 <br /> 's � License P,� <br /> Contractor's Address !fib`'' �- ' Emergency Phone - <br /> Is Certificate of Workman's Compensation !ns ranee on File With SJLwD? Yes - <br /> No <br /> OESTR <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ ❑P INSTALLATION❑❑ PUMP REP <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER <br /> REPLACEMENT❑ Pit Privy <br /> r Sewer Lines _ . <br /> DISTANCE TO NEAREST: Septic Tank e Cess ool/Sea e Pit Other <br /> Sewage Disposal Field p p g <br /> Property_Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL Q <br /> El INDUSTRIAL E] CABLE TOOL Dia. of Well Excavation 1 <br /> 11DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �. <br /> 11 IRRIGATION 11GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> 11 OTHER Other information <br /> Installed B i. <br /> 11 GEOPHYSICAL <br /> Surface Seal - <br /> .r. <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done d <br /> DESTRUCTION OF WELL: <br /> 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 7ichlth <br /> nty <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 the work for rmit <br /> is issued, Ishall not employ any person in such manner as to become subject to-workman's.compensat ion laws of California." <br /> Contractor's Kirin orsub-contracting signature certifies the following:"I c fy that in the performance of the work forwhich this <br /> permit is is I shall a loy persons subject to workman's compe n laws of California." <br /> III r out I spe'ci on prior to grouting and a final inspe n. <br /> & � Date: <br /> SignedX Tit! ' <br /> (Draw Plot Plan on Reverse Side) �' r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE! Date f -/e e <br /> Application Accepted By <br /> Additional Comments: Zase 11! Final Inspection <br /> Phase 11 Grout spectlon Date <br /> r Inspection B Date Inspection By <br /> Fee Is Rue: D ANN A Y ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received M1Tuly 31 \ <br /> BASE EXPLANATION BILLING REMITTANCE $ ' AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> _ LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Date Receipt No. Permit No. - I nuance Date Mailed-- Delivered <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISEAVlCES <br />