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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> EAM%OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspends r _ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT G <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is-=N <br /> made in compliance wit S n Joaqui Counnty Ordinanc No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ` l� City/Town ,_�& c_4E <br /> Owner's Name r �-¢- Phone - <br /> Address `�(' �' Z City pjnG, !9 <br /> a2 <br /> Contractor's Name � �+-1-�-- License#� Business Phone �'�—yS <br /> Contractor's Addressr' � ! �� 3� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes it No <br /> TYPE OF WORK (CHECK): NEW WELL'O 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 Q, <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installe B <br /> PUMP INSTALLATION: Contractor ^- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done IA i <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: 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 Joaquin County <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 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 f rwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." Pjr � <br /> I will c II for a Grout Ins ect• prior to grouting and a final inspecti / <br /> ,'�9� +-.�- - Title: C.��r ; Date: 1 2-: / PC", <br /> Signed X �--- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By \� Q_%JL Date Z <br /> Additional Comments: <br /> Phase�Wrout Inspection pJhase 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEES' 7� <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 95201 <br />