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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) . ! PLA .47—( 7.17 <br /> WA QUALITY . A /�; rk�100 - 07 I; <br /> Application is hereby made to the San Joaquin Local Health District for a�e"rmittoconstruct and/or instal I the work,herein described.This application is <br /> made in compliant San Joa u' ounty Ordinance No" 1862 and the rules and regulations of the San a uin Local Health District. <br /> Exact Site Addres � � City/Town O <br /> Owner's-Name Phone <br /> Address r, <br /> City o� <br /> Contractor's Name 3f3"4 Licerise# Business Phone_ <br /> Contractor's Address Emergency Phone i { <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 ❑ WELL ABANDONMENT El <br /> OTHER ❑ 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 /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL Y <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ElDRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC - ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK X Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY E�:Si Type of Grout I pp <br /> ❑ DISPOSAL ❑ OTHER Other Information u <br /> ❑ GEOPHYSICAL! Surface Seal Installed By: I <br /> PUMP INSTALLATION:. Contractor <br /> j Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done r <br /> PUMP REPAIR: 1 ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �r 7-3-2 <br /> I �' <br /> Approximate Depth {� <br /> Describe Material and Proceda <br /> Q -6 4 T <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit i <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." J <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 employ persons subject to workman's compensation laws of California." <br /> A1z 1 for ns prior to uting nd a nal inspection <br /> Signed Title: �� <br /> Date: <br /> ( raw Ptot"an on Rev a Si ) i <br /> �l <br /> FOR DEPARTMENT USE ONLY T- <br /> PHASE I <br /> • Application Accepted ByD,, <br /> ,.Application <br /> Additional Comments: i <br /> Phase If Grout Inspection I al Inspection '•: <br /> Inspection By DateInspection ��Date -/3 <br /> i' <br /> Fee Is DUB: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE 1:1 EACH ❑ Januar 1 eceived B Januar 31 <br /> Y y y -❑ July 1 &Received By July 31 <br /> BILLING. REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEED !I <br /> C� ;3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> 6 <br /> OTHER <br /> OTHER <br /> sm <br /> Receded by a �1..IptN.; Permit Nu. 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 />