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wppncauvna wise oevrucefisea wnen auommea Properly Gompletea. He Sure To Sign The Application, <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) 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 San Joaquin County�Ordinance No. 1862 find�it�he rules Rod regulations of the San J�quin,�ocal Health District. <br /> Exact Site Address •• `� �' �� +..vf 7%>a" �j�/i City/Town .gG <br /> Owner's Name Q?1.iI�.- ti. / !1,y��...�.-a Phone <br /> Address City /91 <br /> -,r-,. <br /> Contractor's NameLiceriseBusiness Phone_ <br /> Contractor's Address A, Emergency Phone (n <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes tit No W <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 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 <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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 14 <br /> �I <br /> PUMP INSTALLATION: Contractor <br /> �Tyy/pe of Pump - H.P. va <br /> PUMP REPLACEMENT: y Stat Work Done___;-.-.----' <br /> PUMP REPAIR: fft I I,Work Done r <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> U <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County S <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 employ persons subject to workman's compensation laws of California." <br /> I will call fop a Grout inspection prior to grouting and a final inspection. / <br /> Signed X ! +' ',•-z. _ Title- �'wf �--✓ Date: <br /> / (Draw Plot Plan on Reverse Side) <br /> F,OR DEPARTMENT USE ONLY <br /> PHASE I !- , <br /> Application Accepted By �r% — Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <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 /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> /} AMOUNT <br /> FEE 4 4 T7' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 401111' 0 3 S I �L_ <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 95201 <br />