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t Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �H <br /> FOR OFFICE USE: Applications <br /> (Far Non-Transferable,Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSanJoaquin Local Health Districtfora ' <br /> permit to construct and/or install thework herein described.This application Is <br /> made in compliance with San Joa uin Count Ordinance N .1862 and the u es and regulations of the San Joaqui :'Local Health District. <br /> Exact Site Address -�� A� _ City/Town 4s e— <br /> Owner's Name .4A( Phone.: <br /> Address /nr .. <br /> ,-. '- City <br /> Contractor's Name AaQWALIye License# Business <br /> Ph <br /> one, T <br /> , <br /> Contractor's Address J -'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 7 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ElRECONDITION LJ DESTRUCTION❑`WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAiR❑ 41 k <br /> REPLACEMENT❑ —Z <br /> DISTANCE TO NEAREST: Septic Tank.., ` { _ Sewer Lines ! t Pit Privy <br /> Sewage Disposal Field .-e Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well /4- Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL �+ <br /> CABLE TOOL Dia. of Wel! Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �• <br /> A❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing (A&JE/r <br /> IRRIGATION ❑. GRAVEL PACK Depth of Grout Seal k3 lj� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ---- } <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 6z414.147 A <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameterrpximate Depth f <br /> ' <br /> Describe Material and.Procedure App <br /> I hereby certify that I have prepared this application and'that thework will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. V] <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 forwhich this <br /> permit is issued, I shall employ <br /> JJ pers o s s/ ject to workman's compensation laws of California." <br /> I will call fora rout I ec(on pridr uting-an-d a final inspection. i <br /> Signed Title: ,��� Date: f, <br /> (Draw Plot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY c <br /> PHASE I <br /> Application Accepted B Date &L <br /> Additional Comments, . <br /> Phase II Grout inspection h se fl Final-Inspection rt <br /> Inspection By Date " Inspection By Date b Q <br /> Fee Is Due: ❑ ANNUALLY D' <br /> PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received y January 31 ❑ July 1 &Received By July 31 <br /> BASF EXPLANATION <br /> BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER - <br /> i <br /> Received by Date Receipt No. Permit No. - I uance D to Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL:HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />