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r 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) <br /> � S PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMITkQ � <br /> (COMPLET&rINTRIPLICATE)a,0 S, V, r;I <br /> G(,tg, WATER QUALITY 1 <br /> Application is hereby madetotheSan Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is # <br /> e <br /> made in compliance with San o uin Count Ordinan eII o. 1862 and the rules and regulations of the San Joa ip Local Health District. <br /> Exact Site Addres �� I �� City/Town - <br /> Owner's Name °t< [ 1 r�� ���.�� ��� Phone <br /> Addressr J City P E f7n f <br /> Contractor's Name ll I'1 License#r Business Phone <br /> Contractor's Address f� ! ;f-Mergency Phone 50 j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes '� y No <br /> TYPE OF WORK (CHECK): NEW WELL❑' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank t Sewer Lines Pit Privy <br /> 3 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 13 INDUSTRIAL 0`CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE EI- BILLED Dia. of Well Casing L i <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1/4 o n <br /> U-MRIGATION ®RAVEL PACK Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout (A) <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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, 1 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 /> permit is issued,'I shall employ persons subject to workman's compensation laws of California," <br /> I will call for a Grout Ins/p�ec-,t�ion,pprior tco,grouting and a final inspection. /� i <br /> signed X l?I��i�1 �i:( 1/. U f E / ). 4112LU✓L6&ie�.i4_) y.4 T Date: <br /> (Draw Plot Plan on Reversegide) <br /> ORD PARTM T USE ONLY <br /> PHASE <br /> Application Accepted By Date 1 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase II anal Ins ction <br /> Inspection By Date ,1 Inspection By ate �d <br /> �0 J <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received <br /> yJanuary 31 July 1 &Receivetl By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONAMOUNT pUE CHECKED � <br /> DATE DATE REMITTED AMOUNT <br /> r <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER } <br /> 1, <br /> OTHER i <br /> Received by Date Receipt No. Permit No j, Is uance 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 />