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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. x <br /> ' FOR OFFICE 115 r� APPLICATION ��l <br /> (For Non-Transferable, Revocable, Suspendable) Z3 <br /> E <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) . WATER QUALITY <br /> F Application is hereby made to'the San Joaquin Local Health District fora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address . <br /> ity/Town <br /> Owner's Name <br /> Address k:2Phones <br /> Contractor's NameCity i <br /> a.+ License#� 3�4 f Business Phone —] 1 <br /> Contractor's Address r r Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Ile With SJLHD? Yes <br /> TYPE OF WORK (CHECK): No <br /> NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ IX <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ <br /> REPLACEMENT❑ OTHER E] PUMP INSTALLATION �pUMP REPAIR El O'a <br /> DISTANCE TO NEAREST: Septic Tank <br /> p Sewer Lines Pit Privy <br /> F Sewage Disposal Field <br /> Cesspool/Seopage Pit Other <br /> Property Line . Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL A•' ; <br /> ❑ INUSTRIAL El CABLE TOOL Dia, of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br />` 13 "IRRIGATION Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 13 DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: N <br /> PUMP INSTALLATION: Contractor t4 <br /> I Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: , ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' <br /> Approximate Depth <br /> Describe Material and Procedure.. <br /> f <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 /> Homeowner or licensed agent's sign ature,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 fallowing:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c r a Grout Inspection prior to grouting and a final inspection. ,} <br /> Signed Title: <br /> Date: -S= <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTM T U <br /> PHASE I, , <br /> Application Accepted By z� <br /> Additional Comments: Date ��_U 90 <br /> Phase II Grout Inspection Phase!11 Final Inspection <br /> Inspection By Date Inspection By <br /> Date <br /> t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ' <br /> ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> Y DATE D,(FE REMITTED AMOUNT DUE CHECKED <br /> FEE 1 � ) AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Dates Receipt No' <br /> � P �^ Permit Nu. Issuanc Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES�° .w. red <br /> _ .7681 E.HA2ELTON AVE„P.O.Box 2009 STOCKTON,CA 95201 <br />