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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The pp Ica IO <br /> FOR OFFICE USE: APPLICATI <br /> �,. �g <br /> (For Non-Transferable Reyo snd I PUMP&WELL <br /> ml ii- <br /> ENVIRON�TA HEALTH PER <br /> R U Y� V� � <br /> (COMPLETE IN TRIPLICATE) ', <br /> Application is hereby made to the San Joaquin Local Health Districtforapermiit+ structand/or in tall the work.herein.described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and �t�f� a San Joaquin Local Health District, <br /> Enact Site Address 5 'ROown ����r✓.•• <br /> oS <br /> 1E. Phone <br /> Owner's Name <br /> Address 1 City // p <br /> License# c3 3 Business Phone 7`L�?6 - /6 <br /> Contractor's Name s <br /> Emergency Phon( <br /> Contractor's Address �� °�7 j <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes IO <br /> TYPE OF WORK (CHECK):- NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT 13 OTHER E] 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 /> ❑ DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> L1 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11DOMESTIC/PUBLIC 13DRIVEN 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: J <br /> PUMP INSTALLATION: Contractor { <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ <br /> PUMP REPAIR: C&.State Work Done 4Z I.Ce <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 tri 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 /> is issued, I shall not employ any person in such manner as to become subject to workman'a.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 /> l will call for a Grout Inspection-prior to grouting and a final inspection.- <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Sid ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` T <br /> Date <br /> Application-Accepted By <br /> Additional Comments: <br /> Phase II Gro n ection hase III Fin Inspection <br /> Inspection By 4 � Date Inspection By Date <br /> Fee IS Due: ANNUALLY PER UNIT ❑ PE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received <br /> ByI July 31 ' <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 67 <br /> FEE 4S <br /> ­ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER e <br /> Received by Date Receipt No. Permit No, - Iss once Dale Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />