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Applications Will Be Processed When Submitted Properly Completed. <br /> FOR OFFICE USE: APPLICATION <br /> ferable Revocable, Suspendable] i <br /> (For Non-Trans PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER-QUALITY Q�+P S'4arCcQ` <br /> (COMPLETE IN TRIPLICATE) qI __04e--c41lC i - 4. <br /> permltto construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health Districtfora <br /> made in compliance with San Joaquin ounty rdina ce�N�.1 24 d the rules and regulations of the San JoaquiLocal Health District. <br /> 0 City/Town �» <br /> Exact Site Address / <br /> Tutdaaw+d � Phone 0 <br /> Owner's Name City <br /> Address TA.- 8 .-� b <br /> cat <br /> Contractor's Name r__ s�Jo t'"4 License#3�3 ll,A Business Phone_ <br /> Contractor's Address Emergency Phone A - <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes; <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL 19 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 Z CSA Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> i <br /> INTENDED USE TYPE OF WELL J <br /> ❑ INDUSTRIAL ❑ CABLE TOOL W* Dia. of Well Excavation Y <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DRIVEN Gauge of Casing t <br /> EIDOMESTIC/PUBLIC p <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> $` <br /> 11 CATHODIC PROTECTION 19 ROTARY of Grout ROTARY ; <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> i PUMP INSTALLATION: Contractor IIIi !� y'�' 1 <br /> i Type of Pump_ ' Yd r?I H.P. <br /> 75 <br /> I13State Work Done <br /> PUMP REPLACEMENT: <br /> PUMP REPAIR: ❑ State Work Done <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 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 forwhich this permit <br /> I 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 forwhich this <br /> qX <br /> mit is issued, I em oy persons subject to workman's compensation laws of California." <br /> i call f r G ou I spect on prior to gro ti and a final inspection._ <br /> Title: {/ � � Date: <br /> Sign <br /> (D <br /> (Draw Piot Plan on Reverse Side} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE l I C Date <br /> Application Accepted By <br /> I "Additional Comments: ase III Final Inspection <br /> hose I Grout Inspection �c3_l <br /> Inspection By <br /> Date Inspection By Date <br /> ❑ July 1 &Received <br /> Fee Is Due: ❑ ANNUALLY (3 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 REMIT <br /> uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> { 0 <br /> FEE <br /> LESS <br /> PRORATION <br /> I <br /> h PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> bB33IS o . . <br /> . Receipt No. Permit No. Issuance Date Mailed Delivered <br /> IF Received by Date 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br /> SERVICES <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/ <br />