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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) PUMP&WELL <br /> \ � \l ENVIRONMENTAL HEALTH PERMIT s <br /> (COMPLETE IN TRIPLICATE) JJJ WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with JoaquinSan. ount Ordina e 1 62 and t e ru and regulations of the San Joa uif�cal Health Distri t.� <br /> Exact Site Address c d . y J v �(C' 9 City/Towlt ��-l'e u��� �ciT <br /> ! r <br /> Owner's Name Phone <br /> Address Cityro Lw <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No �l <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT19 OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal 41d 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/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTE&ION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICA Surfa a Seal Installedr By: <br /> PUMP INSTALLATION: <br /> �etrtractor^ �n,� — L sn — a '�N 7� p ( G� 10 L- lc CJ� <br /> Type of Pump H.P. <br /> PUMP REPLACiMENT: - ❑ State Work Done <br /> PUMP REPAIFtl ❑ State Work Done 0 Q <br /> DESTRUCTION OF.WELL: Well Diameter Approximate Depth <br /> Describ Mpiterialand%Fjroceclure <br /> R � v <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wit 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 em ;0ersons subject to workman's compensation laws of California." 5- <br /> f ta <br /> 1 will all fo a Grout Inspection rior to grouting and a final inspection. <br /> Signe X' � Title: l� 1-�Q Date: 1 �2'"S2 <br /> ( aw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By D to <br /> Additional Comments: cl__� <br /> Phase II rout Inspection : Kase III Final Inspe on <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> 02 DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <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 9520' <br />